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Policy Statement

This organisation is engaged in the provision of quality care and support to individuals, and recognises its responsibility to ensure that all reasonable precautions are taken to provide and maintain working conditions that are safe, healthy and compliant with all statutory requirements and Codes of Practice.

Legal Requirements

The legal requirement to have a health and safety policy is a direct obligation arising from the Health and Safety at Work etc. Act 1974 (HSWA 1974). It requires that every employer with five or more employees must prepare and revise, as often as necessary, a written health and safety policy for the workplace, and must explain the arrangements for putting that policy into force. This policy and any revision must be brought to the notice of employees. Failure to have a written health and safety policy can result in the issue of an improvement notice ordering the matter to be attended to within a fixed period. Non-compliance can result in prosecution and a fine.

There has been changes to the way that Health and safety responsibilities are now shared between the Care Quality Commission (CQC), the Health and Safety Executive (HSE) and Local Authorities (LA’s) in England. This will mean changes in the inspection regime. This policy sets out to clarify the roles and responsibilities of the three organisations above and to make staff aware of the changes.

On 1st April 2015 a Memorandum of Understanding (MoU) was introduced. The MoU reflects the changes in enforcement powers granted to the CQC by the Regulated Activities Regulations 2014. It replaces the 2012 liaison agreement between CQC and the HSE that applied to Healthcare only.

The purpose of the MoU is to help ensure that there is effective, co-ordinated comprehensive regulation for patients, service users, workers and members of the public. The MoU outlines the respective responsibilities of CQC, HSE and LA when dealing with health and safety incidents in the health and adult care sectors. The MoU is one of the measures taken by government to dose the “regulatory gap” identified by the Francis report into failings at the Mid Staffordshire NHS Foundation Trust.

Respective responsibilities

CQC is the lead inspection and enforcement body under the Health and Social care Act 2008 for safety and quality of treatment and care matters involving patients and service users in receipt of a health or adult social care service from a provider registered with CQC

HSE/LA’s are the lead inspection and enforcement bodies for health and safety matters involving patients and service users who are in receipt of a health or care service from providers not registered with CQC

HSE/LA’s are the lead inspection and enforcement bodies for health and safety matters involving workers, visitors and contractors, irrespective of registration

Annex A of the MoU gives examples of incidents typically falling to CQC or HSE/LA’s to illustrate their responsibilities outlined below.


Examples of incidents that fall to CQC

  • A patient/service user falls from a window

  • A severe scalding incident in a bath/shower

  • Assistance with eating where inappropriate food was given, resulting a serious harm or a death from choking

  • Care given which was not in line with their care plan resulting in serious harm or death

  • Physical restraint by staff which resulted in serious injury or death

  • Ill treatment or wilful neglect of a patient/service user


Examples of incidents that fall to HSE/LA’s

Circumstances where the commissioner of the service rather than the provider, seems to have been primarily at fault

Circumstances where the provider is not required to be registered by CQC

Employees developing dermatitis related to glove use

A manual handling injury to an employee from ill maintained equipment

A contractor tower scaffold collapse into a care home car park

Annex B; Incidents where more specific and exceptional criteria apply

In a small number of cases, more specific criteria may apply and the aforementioned regulators will decide on the appropriate regulator taking into account other applicable legislation etc. A mutually agreed decision will be taken, in line with policy and protection guidance.


Factors tending toward HSE/LA’s leading include;

  • Incidents involving maintenance contractors e.g. scaffolding or asbestos

  • Installed plant for the use of anyone e.g. lifts or escalators

  • Where specific Health and safety at Work legislation can most adequately deal with the cause of the harm e.g. related to statutory examination of plant or the Legionella Approved Code of Practice

Factors tending toward CQC leading include;

  • Incidents that may have exposed staff to harm, but the principle concern is the greater risk to patients or service users.


Factors tending towards a joint or co-ordinated investigation

  • Incidents where commissioners and registered Providers appear to be significantly at fault

  • Employers not required to be registered with CQC as well as registered providers, appear to be significantly at fault

  • Providers who should be registered with CQC but are not. (In such cases CQC would consider the failure to register and HSE/LA’s the specific non-compliance issues.

Annex C covers information sharing to support the MoU and details how the various regulators will share intelligence and the system each will access to do so

In order that the MoU is fully understood by organisations a Health and safety the designated lead post holder will be the advice lead to ensure the appropriate existing statutory requirements for notification of incidents continues, e.g. RIDDOR, and CQC statutory notification requirements.

These changes to health and safety responsibilities are just being implemented and this policy is designed to complement the existing health and safety policies, not replace them.


The Policy

This policy is intended to set out the values, principles and policies underpinning this organisation’s approach to safe working practices.

Health and Safety at Work Policy

This organisation is committed to ensuring the health, safety and welfare of its staff, so far as is reasonably practicable, and of all other persons who may be affected by our activities including visitors, contractors, patients and their relatives. The organisation will take the following steps to ensure that its statutory duties are met at all times:

  • Each employee should be given such information, instruction and training as is necessary to enable the safe performance of work activities.

  • All processes and systems of work should be designed to take account of health and safety and will be properly supervised at all times.

  • Adequate facilities and arrangements will be maintained to enable employees to raise issues of health and safety.

  • Competent persons should be appointed to assist in meeting statutory duties including, where appropriate, specialists from outside the organisation.

  • This document will be regularly monitored to ensure that its objectives are achieved. It will be reviewed and, if necessary, revised in the light of legislative or organisational changes.

Duties on the organisation

The organisation recognises its responsibility under the HSWA 1974 and the Management of Health and Safety at Work Regulations 1999 (MHSWR) to ensure that all reasonable precautions are taken to provide and maintain working conditions which are safe, healthy and compliant with all statutory requirements and codes of practice. Employees, patients, contractors and visitors are expected to abide by safety rules, and to have regard to the safety of others within the organisation.

This organisation’s policy is, so far as is reasonably practicable, to apply the following:

  • Make a suitable and sufficient risk assessment of all work activities and of every patient’s home before a member of staff is allocated to that home

  • Negotiate appropriate risk management measures to reduce any identified risks or hazards to an acceptable level

  • Communicate agreed risk management measures to all necessary persons and staff involved and to ensure regular monitoring of risk levels

  • Provide and maintain equipment such that it is safe and appropriate to use

  • Provide any relevant and appropriate protective equipment or clothing required by staff to perform their role safely

  • Arrange for the safe and healthy use, handling, storage and transport of articles and substances

  • Provide the information, instruction, training and supervision required to ensure the health and safety, at work, of employees and others

  • Control and maintain the organisation’s offices in a safe condition, with appropriate risk assessments and management as above

  • Provide a safe means of access to and exit from the place of work

  • Maintain a working environment that is safe, healthy and equipped with adequate facilities and arrangements for welfare at work

  • Conduct, record and implement the findings from regular risk assessments performed in accordance with Regulation 3 of the MHSWR

  • In the event of any accident or incident (such as a near miss) involving injury to anybody, to make a full investigation and to comply with statutory requirements relating to the reporting of such incidents

  • Appoint a Health and Safety Manager.

The Health and Safety Manager for the organisation is Debbie Orme.

Duties on employees

The successful implementation of this policy requires total commitment from all employees. Each individual has a legal obligation to take reasonable care for their own health and safety, and for the safety of other people who may be affected by either their acts or omissions.

It is the policy of this organisation that, under s.7 of the HSWA 1974, it is the duty of every employee at work:

  • To take reasonable care of their own health and safety and those of any other person who may be affected by their acts or omissions at work

  • To co-operate with their employer to enable any duty or requirement to be complied with that is either imposed on their employer by or under any relevant statutory provisions.

In addition, no person employed by the organisation shall intentionally or recklessly interfere with or misuse anything provided in the interests of health, safety and welfare in pursuance of any statutory provisions. Failure to abide by this policy will be considered a disciplinary offence.





Related Policies

Accident and Incident Reporting (RIDDOR)

Basic Life Support

Control of Substances Hazardous to Health (COSHH)

Fire Safety

Food Hygiene

Infection Control

Lone Workers



Protective Clothing and Equipment

Risk Assessment

Patient’s Records (Home)

Training Statement

All new staff should be encouraged to read the policy on health and safety as part of their induction process. In addition, all staff will be appropriately trained to perform their duties safely and competently, and those staff who need to use specialist equipment will be fully trained and supervised while they are developing their competency.


This policy will be reviewed by the Registered Manager.


Date: January 2023

Review Date: January 2024

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