Health, Safety & Environment Committee

SAF16-P20 8 June 2016

Ref: Date: 13/5/16

Paper Title: Report from the Health, Safety and Risk Manager

Neil Budworth Origin:

1. Specific Decision Required For information – to note and acknowledge analysis and future plans by Committee 2. Relevance to University Aligned with University policy Strategy 3. Executive Summary Details of the evaluation of the University Health and Safety processes and culture based on the first 3 months of tenure of the University Health, Safety and Risk Manager 4. Essential Background Report provides details of benchmarking activity undertaken, data analysis Information and stakeholder discussions before highlighting areas for development and recommending a strategic approach. 5. Risks, Risk Mitigation Details within the document and Governance/ Accountability 6. Implications for other If adopted the approaches would impact University wide activities 7. Resource and Cost As currently written would involve a slight costs reduction in relation to the Health and Safety Service. 8. Alternative Options considered 9. Other Groups/Individuals consulted. 10. Future Actions, If broad agreement if reached a detailed plan of work will be brought forwards Timescales and Frequency in October. A number of the recommendations identified are elsewhere on of Review by this this agenda for approval. Committee. 11. Success Criteria (KPIs) Improved awareness, better compliance and reduced incidents rates. KPIs to be defined more formally when the data capture elements are properly established. 12. University Executive comment (required for Council papers only)

Introduction

Over the last three months, since February 2016 the systems and culture of the University have been evaluated.

The evaluation has been undertaken in a number of different ways. To ensure that issues are viewed in context a number of benchmark visits have been undertaken to Warwick University, Nottingham University and De Montfort University.

There has also been some analysis of the incident data which is available via the University Health and Safety Association (USHA) / Higher Education Statistics Agency (HESA) and of the incident data which we hold as a University.

Semi structured meetings have also been held with University stakeholders eg Senior Leadership Team, Deans, Operation Managers, Directors of Functions and selected academics.

Finally over the last few months there has been the direct observation of the management of Health and Safety across the campus.

Key findings from Benchmark Visits

• In all of the Institutions visited there was recognition that the health and safety landscape was changing and that senior management needed briefing about those changes. • All of the Institutions visited had a strong focus on Fire safety with some kind of dedicated advice provided on that subject. • There was generally a stronger network of Departmental and School Safety Officers with in some cases the post holders being trained to a high level in Health and Safety (NEBOSH Diploma) • Warwick and De Montfort have a formal internal Improvement and Prohibition notice system, although both use it as a last resort. • Incident reporting systems are on line and networked across the University in all of the Institutions visited. • Most had a similar committee structure to Loughborough, with committees focusing on specific risks eg Committees on Radiological Protection Fire, Biological Safety etc • There were a variety of Occupational Health models in use with both internal and external resources used, however all of the Institutions visited had greater available resources than Loughborough •

Incident Rate Benchmarking and Data Analysis

Benchmark Data

Health and Safety Incident Data is easily accessible via the University Health and Safety Association (USHA) members’ web site. The data has been compiled by the Higher Education Statistics Agency (HESA).

The most common criteria used for benchmarking in Health and Safety is all RIDDOR Incidents ( Incidents reported to the HSE in line with the requirements of the Reporting of Injuries, Diseases and Dangerous Occurrence Regulations 2013). The reason that this is a popular choice for benchmarking is that there is statutory definition specifying exactly which incidents have to be reported, and, as these tend to be the more serious incidents they are more likely to be identified and reported consistently. Whilst this standard to some degree eliminates the variation that can occur due to the difference in sensitivities of reporting systems and the level of awareness of reporting mechanisms across Institutions, it does result in benchmarks being made against small numbers of incidents.

To allow for Institutions of different sizes to be compared incident rates are calculated showing incidents per 1,000 employees or per 10,000 students.

Three comparator groups have been selected, the 1994 groups of Universities, all Universities with between 3 and 4,000 staff and all Universities with between 10 and 20,000 students. Two of which are shown below.

The University of Northampton The University of Brighton The University of Strathclyde The University of Aberdeen The University of Surrey The Manchester Metropolitan… The University of York The University of Bath University of Durham University of the West of England,… The University of Sussex University of the Arts, London The University of Lancaster Leeds Metropolitan University The University of Hull The University of Reading University of Hertfordshire Sheffield Hallam University London School of Economics and… Swansea University The University of St Andrews The University of East Anglia The University of Leicester The Queen's University of Belfast Loughborough University The University of Kent The University of Plymouth Liverpool John Moores University University of Ulster The Nottingham Trent University Queen Mary University of London The University of Northumbria at… The University of Exeter The University of Central Lancashire Coventry University 0.00 1.00 2.00 3.00 4.00

Total RIDDOR Incident Rate per 1000 staff Universities with between 2,000 and 4,000 employees Based on 2013 Data

Total RIDDOR Incident Rate per 10,000 Students Universities with between 10,000 and 20,000 Students Based on 2013 Data

Total RIDDOR Incident Rate per 10,000 Students Universities with between 10,000 and 20,000 Students Based on 2014 Data

Analysis of Benchmark Data

Clearly Loughborough is not ideally placed in these comparisons. There are a number of possible explanations.

Firstly that we have a more robust reporting system than other institutions - Whilst we may have a high level of awareness of incident reporting, we have several manual reporting processes, which do not give the same level of universal access and automatic routing of reports that would be expected in a modern incident reporting and investigation software package

So a high level of awareness, and a less developed reporting systems tend to balance out. The statutory reporting threshold specified in RIDDOR itself also tends to lead to more consistent reporting across institutions.

The second possible explanation is that we are over represented in a particular category of incidents, specifically the ‘over 7 day’ injuries and the member of the public conveyed directly to hospital categories. The first of these are incidents where the injured party has been absent from work for more than 7 days following an incident. From the data we can see we do appear to have more injuries in this category than other institutions. This could be because we are having more serious incidents, because we are more scrupulous about tracking the absence or because we are not managing post injury absence as well as other institutions. Further investigation is warranted related to this category of incident.

In relation to the second category, we are fortunate to be located in very close proximity to the Loughborough Urgent Care Centre. In some cases injured parties are transported to the Urgent Care Centre for assessment and treatment. If a student is involved, the action of taking them to the Urgent Care Centre alone automatically makes the incident a RIDDOR reportable incident. If the Urgent Care Centre was less accessible some of the cases we have may well have been dealt with by on site first aiders.

The final possibility is that we are suffering more incidents than our peers. This may be the case as many of the Universities with whom we are benchmarking outsource the facilities Management and catering activities and these are the areas in which we suffer the most incidents.

The reality is probably a mixture of these four explanations.

The only real conclusions that we can draw from the benchmarking is that the only really reliable benchmark is against ourselves year on year and that there is room for improvement.

Pareto Analysis

Pareto Analysis is a management tool which is used to help to identify the areas where attention should be focused. In terms of Health and Safety we use it to seek to determine which areas suffer 80% of our incidents, and which incident types make up 80% of our incidents.

Pareto analysis was conducted on the available accident data to determine in which areas we are suffering most incidents and the types of incidents that are most prevalent.

The majority of our recorded incidents associated with (in order) Campus Living, Facilities Management, the School of Science and Sports Development Centre.

In terms of type of incidents, cuts on sharps or glassware appear the highest cause of injury. This is untypical, so further investigation will be undertaken to see if we can determine what actions can be taken to reduce the number of these injuries.

Year on Year Trends

Examination of the number of incidents reported in the 1st quarter of the year between 2012 and 2016 shows that the numbers were stable between 2012 and 2014, and that we have seen a substantial reduction in 2015 and 2016 with 2016 incident numbers being approximately 16% lower than those of 2014.

Whilst this in itself is good news, it should be received with a degree of caution, as between 2013 and 2015 the number of RIDDOR incidents reported increased from 11 to 16. These are small numbers, but it is generally accepted that there is a fairly constant ratio between the number of more serious incidents reported and the total number of incidents occurring. The implication being that we are either becoming looser in our reporting of RIDDOR incidents, awareness of the reporting process for minor incidents is starting to decline, or we are suffering more serious incidents.

Initial Observations Following Discussions with Stakeholders and on Site Observations

Although the people who create and work with the risks are largely aware of them, there is no comprehensive view of what the key risks are by school or by department. This in turn means that there is no direct ‘line of sight’ between the risks being generated and the senior leadership who carry the responsibility for the management of those risks.

In addition to this, individual responsibilities are not always clear to those who hold them, as they are often specified in the text of a large number of policy documents. This in turn makes holding people accountable for their action or inaction difficult.

There are a variety of incident reporting systems in use at the University. All the systems have a different form and all the systems require multiple manual re-entry of data. As the systems are manual systems, there is no automatic escalation or alert function. Data analysis, trending and reporting is difficult and labour intensive.

In terms of incident investigation there has been a tendency for incidents to be investigated and dealt with within the school or department. This has in some cases led to a lack of pace in the investigation and associated response. The overall result has been missed opportunities to learn lessons across the University.

There has been no consistent mechanism for spreading the lessons learned from incidents or from material received from outside the University.

The approach to the communication of Health and Safety related issues has been partially effective, with visible improvements in certain Safety related scales on the staff survey over recent years. However more targeted communication may help to gain further acceptance of the key safety messages.

Good feedback has been received from schools and departments on the support that they have received from individual members of the Health and Safety team, but there is a level of frustration in some areas with the overall level visibility of health and safety on the campus.

There is a well established network of Departmental and School Safety Officers which could be further enhanced to provide better support and advice close to the actual point of risk.

On the face of it there is not a consistent process to identify critical health risks and ensure that appropriate health surveillance is in place.

There is little consistency in the approach taken to the assessment and control of risks in different schools and there is some demand from some schools for a more consistent, supportive approach. In particular there is some demand for a more consistent approach to forms and data capture.

The lack of consistency relating to forms and processes illustrates the fact that there are multiple health and safety cultures across the University.

In the recent past there have been some issues relating to legislative compliance, mostly around infrastructure issues. The University is in the process of introducing a process which will help to robustly identify potential areas of non-compliance. Significant support will be needed from the Central Health and Safety Service to support the implementation of the compliance assessment process. In additional support will be needed in the definition and reporting of key performance indicators which will be used in the future to help to track compliance.

The future development of the University will require more support in relation to Biological and Chemical safety. Although there have been a few recent issues Radiological safety is generally well managed and in steady state. It is fair to say that the processes and procedures surrounding chemical and biological safety lag behind those in place for radiological safety.

As a University we have some world class experts in ergonomics, design, communications, effective safe construction etc., but we do not tend to make best use of these experts on our own site.

Immediate Actions

External legal briefings have been arranged for all Deans, Directors and Heads of Function and Operations Managers. These briefing sessions will take place in mid May.

The key safety responsibilities of these posts (Deans, Directors and Heads of Function and Operations Managers) have been consolidated into a single document which is being issued at the training in May.

The incident reporting and investigation policy has been reviewed to include the requirement to immediately notify senior officers of any serious incident. The policy also requires that independent, or semi-independent investigation teams are established for more serious incidents, or for incidents with serious potential.

Finally this policy also requires that serious incident investigations be subject to a senior management incident review panel where the investigation findings are probed and lessons learned.

To support the processes established in the revised incident reporting policy, detailed incident investigation guidance has been drafted and consultation has taken place on the use of a Fair and Just culture flowchart.

To further support the learning of lessons across the University a safety alert system has been established and is in use.

An independent review of the health surveillance programme has been undertaken and we are now working through the recommendation of the report.

A briefing day has been arranged for Departmental and School Safety Officers. In addition a training matrix has been developed which links the recommended level of training with the risk rating of the Department or School.

Contact has been made with a number of academics Professor Alistair Gibbs, Professor Roger Haslam, Professor Cheryl Haslam, Nicola Bateman and Professor Elizabeth Stokoe with a view to identifying areas of collaboration.

So far, a pilot well being programme – Walking Works Wonders is being established in Corporate Services with Professor Cheryl Haslam and a small research project on enhancing the influencing behaviours of staff with safety responsibilities is being commissioned. Opportunities to involve other academic specialities will be sought as our plans develop.

Team Structure to Support Future Activity

Likely support needs

Facilities Management and Campus living continue to be the biggest source of incidents for the University, hence it is important that looking forwards any team structure provides high levels of support for these areas.

In addition statutory compliance continues to be a significant concern and support is needed to maintain and manage the systems that support and drive compliance. This activity is also closely related to the Facilities Management function and hence should sit in the same managerial area as the advisors to those teams.

There is already evidence of a growing need for biological and chemical support and the need for high levels of radiological support will continue due to the strict regulatory requirements in this area, hence more resource will be needed in these areas.

Fire protection continues to be an important issue and the need to ensure that the means of protecting live and assets is properly specified and installed remains a focus.

There is a disparity of approach in the way that Health and Safety training is administered in FM compared with the way it is administered in the legacy health and safety service. With the merger of the two Health and Safety functions there is an opportunity to harmonise the approach to training and take the best practice from each area.

The incident reporting arrangements and data management are weak and need some focus in the new structure. The opportunity will also be taken to enhance the way in which we communicate.

There may be an opportunity to centralise and / or automate some of the existing processes, however this will just allow the team to provide the service which is now being required he University.

Schools and department are being allocated a team member to act as a business partner and the underlying principle of the new structure is that the team will build relationships with their nominated departments, but they will be expected to use their expertise as appropriate across the University.

Proposals for structural changes will be submitted to the Operations Committee following this meeting, but should generate a small cost saving.

Recommended structure

Health Safety and Risk Manager

Deputy Health and Safety Deputy Healt, Safety and Risk Fire Safety Officer Manager Manager Radiological, Chemical (Support for Schools and (FM, Campus Living , and Biological Safety (Fire safety, standards, Departments, Training, Incide Compliance and Risk Officer design, implementation and audit) Reporting and analysis, and Management Programme) support of DSO/ SSO network

Compliance Fire Safety Training Co- Engineer Technician ordinator

Health and Safety Health and Safety Administrative Co-ordinator Assistant

Health and Safety

Co-ordinator

Future Plan

The Health and Safety Service are meeting in late May to fully populate the strategic plan and detailed plan of work (there will then be some consultation around the elements of strategic plan), hence the detail of this plan is not presented here. Major elements of the plan will be subject to consultation and discussion with the appropriate stakeholders.

However, there are some elements of the plan which can be outlined.

The clear identification of risks and responsibilities :- In line with the guidance produced by UCEA and USHA to develop a management system which aligns with the published guidance ( HASMAP). Specifically this will require the generation of health and safety risk registers for each school and department, which will take 12- 18 months to produce and embed. Detailed proposals will be brought to the Health, Safety and Environment committee. The risk registers will eventually form the basis of the local health and safety plan, they will indicate the priority areas of audit and ultimately become the yardstick against which progress is measured. Clear ownership for each risk will be identified.

We will work with the leadership of the University to ensure that they are aware of their responsibilities and the risks within their area of control and we will develop the standards, tools and metrics to help the senior leadership to discharge their responsibilities.

Training and awareness :- the health and safety training matrix will be updated and communicated across the University. Particular attention will be paid to defining the mandatory and aspirational training for Departmental and School Safety Officers.

To improve levels of awareness and to ensure lessons are learned, our communication strategy will be reviewed and channels such as ‘Safety Alerts’ and monthly reports are introduced.

Support for Schools and Departments :- The provision of help and support will continue to be a focus of the Health and Safety Service. Business Partners will be allocated for each school or department. In addition we will seek to identify opportunities to harmonise procedures or forms where appropriate.

Data capture and use :- The way in which we capture, analyse and present information will be reviewed. In particular the incident reporting process will be reviewed with a view to re-engineering the process and then automating the process. Our data analysis will inform our communication strategy and work plan.

Making the Most of Our On Site Experts - We will seek opportunities to work with and learn from our academic colleagues where we have expertise on site.

We will work with the departments and the Occupational Health team to minimise the potential of work related illness.

Detailed work plans have been developed for each area.