Health and Safety Management Framework

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  1. Introduction

At Imperial the safety of all staff, students, contractors, and anyone else affected by the University’s activities is recognised as being of prime importance. Senior management are fully committed to achieving a strong safety culture and understand that establishing and maintaining such a culture requires high standards of safety management, demonstrable leadership, and personal commitment from everyone.

Health and Safety risk for Imperial reflects the diversity of its activities; the University hosts high hazard activities including those involving dangerous pathogens, genetically modified organisms, ionising radiation, lasers, cryogenic gases, chemical substances, and laboratory animals. We operate from multiple locations in the UK and overseas, our activities range from leading edge research and innovative teaching to the construction of state-of-the-art facilities with safety control by design features. Departments and Faculties lead on the operational safety management of their activities, supported by the University Safety Department. This devolved accountability means that organisation level Health and Safety oversight, and reliance on reporting from Faculty and Department level in a clear framework, are key to Health and Safety governance.

  1. Objective

The objective of Imperial is to reduce Health and Safety hazards, and associated risks as far as reasonably practicable in the context of delivering the University’s strategic goals. The aim of this framework is to define the processes in place to provide assurance that Health and Safety at Imperial is being appropriately managed and meets the requirements of Health and Safety legislation.

  1. Health & Safety Management

Imperial’s Health and Safety Management system is based on the Health and Safety Executive’s guidance ‘Managing for Health and Safety’ (HSG65) Plan, Do, Check and Act approach.

Plan, Do, Check, Act

Policy and Arrangements (Plan)

Imperial has the following in place:

  • A documented Safety Management System (SMS) available on the University intranet.
  • Health and Safety policy statement
  • Policies for high-risk activities such as lone working and out-of-hours working and protocols for managing emergencies
  • Health and Safety Codes of Practice and handbooks at departmental level
  • Specific guidance for specialist areas – biological, radiation, chemical and process safety

The purpose of these documents is to clearly describe how Imperial will manage health and safety so that everyone, from staff to stakeholders, understand their role and are committed to providing a safe working environment. This will enable Imperial to meet the requirements of Health and Safety legislation.

Implementation (Do)

The SMS is implemented through:

·         Risk profiling and control - the process of assessing Health and Safety-related risks for staff and others. Specific systems have been developed for managing complex risk assessments.

·         Safe working practices - The control of general risks affecting all employees are dealt with by several general rules, as detailed in the SMS. Specialist areas such as laboratory activities, field work and Estates safe working practices are described in specific policies, standard operating procedures, and work instructions. Access to high-risk areas and out of hours operations is controlled through digital or swipe card systems.

Imperial also has in place an Occupational Health provision, which is a Primary Care speciality which uses the Biopsychosocial Model of Health to understand, protect and promote health at work. At Imperial this is an advisory service which is primarily focused on Health Protection at Work and Workplace Wellbeing consultations (management and self-referral for staff). Imperial’s Occupational Health works in partnership with teams in People and Organisational Development, and Student Services to prioritise the physical and mental health of the community.

The University has a focus on health and wellbeing, including a Mental Health and Wellbeing Strategy. Available provisions include resilience and stress management, first line counselling, Mental Health First Aiders and physical health activities. Details of these are available at https://www.imperial.ac.uk/health-and-wellbeing/ and https://www.imperial.ac.uk/student-support-zone/your-wellbeing/ for staff and students respectively.

Occupational Health also have defined procedures for managing common notifiable diseases which may arise across Imperial, especially within the halls of residences.

Imperial has established maintenance and repair programmes. The type, frequency and depth of maintenance activities reflect the extent and nature of the hazards and risks identified through the risk assessment process. In conjunction with its facilities maintenance providers, Imperial has in place a programme of planned repair/replacement of components, elements or systems, a programme for servicing of equipment and a programme of routine inspections to ensure it provides and maintains a safe and healthy workplace. Most departments have localised maintenance and service programmes for their range of specialist equipment.

Performance monitoring (Check)

Monitoring performance is essential to maintaining an effective Health and Safety management system and improve Health and Safety performance. There are two forms of performance monitoring undertaken:

  • Proactive monitoring which provides the University with feedback on its performance before an accident or incident or ill health occurs.
  • Reactive Monitoring which provides the University with feedback on performance following an accident, near miss incident or untoward event.

Details of the monitoring activities undertaken are attached (Annex 1)

Incident reporting and investigations

Health and Safety investigations form an essential part of the monitoring process. Findings from incident investigations can help identify why existing risk control measures failed, form the basis of action to prevent an incident from happening again, and improve overall risk management. The University’s investigations guidance https://www.imperial.ac.uk/safety/safety-by-topic/safety-management/investigations/ outlines the requirements for identifying, managing, investigating, and reporting accidents, incidents, and near misses.

There is a legal requirement to formally report certain work-related injuries, cases of ill health and dangerous occurrences under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR). This reporting to the Health and Safety Executive (HSE) is undertaken by the Safety Department.

If anyone has any concerns about their own safety or poor safety practices, they can raise it with their local safety personnel, trade unions, report it on SALUS, or they can contact the Safety Department at safetydept@imperial.ac.uk

Continuous Improvement (Act)

Auditing and reviewing performance are essential to learning from experience, and to improving the Health and Safety management system through the development of policies, procedures, and techniques.

The Safety Department conducts annual audits of the Safety Management System, as implemented by each of the Faculties and Support Services. These audits are based on Plan, Do, Check, Act approach as given in the Universities Health and safety Association (USHA) HASMAP model with three levels of compliance basic, substantial, and high.

A review of Imperial’s management system and the activities of the Safety Department are monitored by external independent auditors and inspectors including the Health and Safety Executive, Environmental Agency, Department for Environment, Food & Rural Affairs (Animal and Plant Health Agency) and Counter Terrorism Security Advisors. Specialist external audits/inspections are also undertaken as required.

Learning lessons. The key purpose of collecting information from incidents and near misses is to learn from them and act upon them. Where appropriate, incident outcomes are shared through team meetings and Committees, H&S Safety Forum, the HS&E Committees, the monthly dashboard and via the Safety Newsletter.

4. Responsibilities

The day-to-day operational management of Health and Safety rests with Faculties and other business units. Imperial has a central Safety Department with specialist safety advisers for Biological, Radiation, Chemical and Process Safety, who provide advice on complex projects and define University Policy for the management of these hazards. They also monitor compliance and provide assurance to senior managers and Imperial leadership.

The delivery of Workplace Health interventions for staff and students is managed by an in- house Occupational Health team led by specialist registered Occupational Health practitioners https://www.hse.gov.uk/health-surveillance/occupational-health/assessing-competence.htm. Employee wellbeing is supported by the People and Organisational Development team, while Student Health and Welfare services (non-occupational) are managed by the Director of Student Services. Fire safety is managed through a dedicated Fire Office. In addition, Imperial has appointed highly trained Safety Officers within Departments and dedicated Safety Advisors at Faculty Level.

Specialist Working Groups have also been established for specific hazards such as Travel Risk, Animal Research, Asbestos Management, Water Safety, Cryogenic gases, etc.

It is a legal requirement (https://www.hse.gov.uk/pubns/books/hsg65.htm) for all employees to be consulted about health and safety issues that affect them in the workplace. The University encourages and supports employee consultation and acknowledges the importance of employee involvement in promoting a positive safety culture. Consultation is achieved through the HS&E Consultative Committee where there is representation from Trade Unions representing staff (https://www.imperial.ac.uk/staff/joint-trade-unions/). This forum enables staff representatives to raise Health and Safety issues that may be of concern and cannot be resolved at a local level.

All staff and students have a legal duty to ensure that they take care of themselves and others, to co-operate with the University and the local arrangements to achieve high standards in Health and Safety. Imperial expects all staff and students to be aware of their responsibilities and the Health and Safety arrangements in place. All staff and students are expected to contribute to improvements in Health and Safety wherever possible and must undertake the required mandatory general and role-based Health and Safety training.

In addition, there are key roles that have distinct responsibilities which are detailed on the Safety Department Webpages) https://www.imperial.ac.uk/safety/safety-by-topic/safety-management/health-and-safety-management-system/structure-and-responsibilities/safety-management-roles-and-responsibilities/.

5. Governance

Imperial has defined HSE governance and management structures (figures 1 & 2) and oversight from the Council, to ensure that the University meets its duties of care, regulatory and legal requirements relating to Health and Safety. Each of these bodies regularly reviews performance, compliance, incidences, and risks, in accordance with their annual patterns of work.

Figures 1 and 2

Figure 1: Health and Safety Governance structure

Figure 1: 

Figure 2: Health and Safety management structure

Figure 2: 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health and Safety are also discussed at Faculty management meetings and Department Health and Safety Committees. Matters from these committees relating to University wide issues are subsequently addressed at the HSE Management Committee.

6. Competency and Training.

Imperial acknowledges that effective Health and Safety management requires adequate resources and competency across all levels of the University to ensure that activities are safely managed. Imperial must ensure all employees are competent, and have the relevant experience, skills, and knowledge to carry out their work safely and without risk to their health. Imperial’s Health and Safety training needs are identified and addressed by the Health and Safety Training Implementation Committee (HSTIC) and are reviewed annually.

All staff and Post Graduate students are required to undertake the Day One Induction and Imperial Essentials on-line training which includes the Month One Safety Training (MOST) and Fire Safety Training modules. Role specific training is also required as detailed in the Safety raining Matrix https://www.imperial.ac.uk/media/imperial-college/administration-and-support-services/staff-development/public/safety/Role-based-training-matrix.pdf. Safety leadership and new behavioural safety training is also offered to help improve the safety culture. Additional training for specialist roles is detailed and provided at University, Faculty or Departmental level.

All Undergraduate students are provided safety induction training at the beginning of the first term by their faculty or department safety officers. Further safety inductions are provided to students where the course includes working in laboratory areas, workshops or attending field trips. These are detailed and delivered at local Department level. Those living in halls of residences are provided further safety advice by the residences staff and wardens.

The University follows the Health and Safety Executive’s guidance to determine the recommended number of fire wardens and first aiders required in each workplace. Based on this assessment, fire wardens and first aiders are recruited and trained accordingly.

7. Health & Safety Communications and Reporting

University departments and support services departments hold termly Health and Safety Committee meetings to discuss local safety concerns, accidents & incidents data, audit findings, plans and achievements.

Building User Group and Campus User Group meetings are held termly and provide additional opportunities to discuss Health and Safety issues.

The Safety Department holds regular meetings with all Faculty Safety Advisors (and their equivalent in business units and support services) on a collective and individual basis.

Health and Safety issues are communicated to employees through Imperial web pages, Staff briefings, H&S Safety Forum, posters and leaflets, and team meetings.

A series of reports are also produced to be presented and discussed:

  • Safety Department report is produced each term for Faculty/Department Health and Safety Committee meetings.
  • Occupational Health report is produced termly for Health and Safety Committees
  • Health, Safety, and Environment dashboard is produced monthly for members of the University Management Board, Operations Committee, the Risk and Compliance Committee and the University safety advisers.
  • Health & Safety report is submitted each term to the University Management Board.
  • Annual report on safety, fire, health, and wellbeing is presented and discussed at the University Management Board, the Audit and Risk Committee of Council and sent to Council.

Annex 1: Monitoring Activities

Annex 1: Monitoring activities

Imperial undertakes two types of monitoring proactive and reactive, which are detailed below:

Proactive monitoring

Imperial undertakes the following proactive performance monitoring measures:

  • Regular safety inspections at University, Faculty, and Departmental level
  • Activity specific audits e.g., Liquid Nitrogen, Laboratory animal designated rooms, radiation designated laboratories, containment level 3 laboratories, etc.
  • Review of policies - each health and safety related policy and procedure has a review date. The content and effectiveness of each of these policies is reviewed when it becomes due or following regulatory changes or adverse events.
  • Regular environmental monitoring is undertaken such as for laboratory animal allergens (LAA), volatile organic compounds, heavy metals, oil mists etc.
  • Review of risk register - the University’s significant risks, including Health and Safety are reviewed by the Risk and Compliance Committee and the Audit & Compliance Committee, along with planned actions to reduce these risks.
  • Compliance with planned preventive maintenance (PPM) - this forms part of the premises and equipment maintenance programmes.
  • Training compliance - a review of compliance with mandatory Health and Safety training is part of the Imperial Essentials programme and compliance levels are available to line managers.
  • Health surveillance for COSHH (https://www.hse.gov.uk/health-surveillance/record-keeping.htm) where risk assessments indicate it is necessary and there are validated clinical interventions to assess the adverse health effects of exposure to a health hazard. Such records are currently managed separately from medical records.
  • Staff Survey - Imperial undertakes periodic staff surveys which includes questions on Health and Safety related issues. The results of the staff surveys are disseminated throughout the organisation.
  • MOUs are in place with NHS Trusts at shared campus sites and with other partners
  • The following KPIs are in place at operational level:
  • Maintenance records for critical safety controls
  • Emergency evacuation drills (Fire Office)
  • Emergency drills planned and conducted within high-hazard areas
  • Salus entries investigated where the actions identified have been implemented (and therefore the entry is closed)
  • Audits and inspections conducted and closed
  • Visible leadership

 

Reactive Performance Monitoring

This type of monitoring provides Imperial with feedback on performance following an accident, near miss incident or untoward event. The following reactive monitoring takes place at University and Faculty level:

  • The number and type of staff and student accidents reported each month, including rolling averages over time
  • The number of RIDDOR reportable incidents to staff, students, and others each month
  • Comparison of the number of near-miss incidents and accidents reported