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For the Health and Safety Joint Committee

REPORT OF THE 2015 HEALTH & SAFETY SELF-ASSURANCE EXERCISE

AND

HEALTH & SAFETY MANAGEMENT PROFILE (HASMAP) AUDITS

1. SUMMARY

1.1. The report outlines a summary of the common findings and performances as identified during the University’s 2015 Health and Safety Self-Assurance1 exercise and its ongoing Health and Safety Management Profile (HASMAP)2 audits.

1.2. Section 3 covers the health and safety self-assurance exercise, identifying where areas have improved since the last questionnaire was completed in 2013. It also highlights areas where further improvements might be made, at both a departmental and University level. The latter being taken forward in Section 5 as ‘Areas for Development’.

1.3. Section 4 provides an update on the HASMAP audit process, with a comparison to the 2015 self-assurance findings. It also notes changes to the higher education sector’s own health and safety management guidance and audit standards, with an indication of how this relates to the University.

2. ACTION REQUIRED

2.1. The Joint Committee is asked to review the report.

2.2. The Joint Committee is asked to endorse the use of the updated 2015 HASMAP standards as its benchmark for health and safety management auditing, in preference to the previous 2007 standards, as outlined in Section 4.3.

2.3. The Joint Committee is asked to consider and approve the identified ‘Areas for Development’, as outlined in Section 5.

1 http://www.admin.ox.ac.uk/safety/selfassurance/ [Self-Assurance]2 http://www.admin.ox.ac.uk/safety/policy-statements/s1-11/ [HASMAP]

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3. FINDINGS FROM THE 2015 HEALTH & SAFETY SELF-ASSURANCE EXERCISE

3.1. 2015 Self-Assurance Submissions

3.1.1. One hundred and twenty departments were asked to complete a self-assurance questionnaire in 2015, of which seventy-five have so far submitted (Figure 1).

Figure 1: Number of departments submitting a 2015 H&S Self-Assurance Questionnaire

3.1.2. This is lower that the eighty-seven questionnaires submitted in 2013. However, there are still a number of questionnaires that are close to completion or require the head of department’s final approval. The final submission rate is likely to be similar to that of 2013, although due to forthcoming changes to the program software, it will not be possible to obtain questionnaires from all one hundred and twenty departments.

3.1.3. It should be noted during the three years this exercise has run; at least one submission has been received from a total of one hundred and thirteen different departments. Furthermore, the HASMAP audit process and divisional health & safety reviews have helped cover those areas where questionnaires have not been completed. This will continue with the planned UAS Health & Safety Review in 2016, thus capturing many of the departments listed as ‘Others’ (Figure 1).

3.2. 2015 Self-Assurance Performance

3.2.1. The health and safety self-assurance was developed alongside the existing University’s Health and Safety Management Audit (HASMAP) program, such that nine of the ten questions correspond directly to the HASMAP indicators. For each question there was a series of statements that reflected different performance levels directly linked to the corresponding HASMAP performance levels; ‘Level 0’, ‘Level 1, ‘Level 2’ and ‘Level 3’. ‘Level 3’ being the performance level that has been agreed through University policy as the level that departments should be aiming to achieve. Departments were asked to select the statement/performance level that best reflects their current management system.

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3.2.2. The following graph provides a summary of the performance levels averaged across the University (Figure 2). For information, the performance level for individual divisions is supplied in Appendix A.

Figure 2: Comparison of the average performance scores from the self-assurance questionnaires completed in 2015 and 2013.

3.2.3. There was no significant difference from the reported performance scores between the 2015 and 2013 (Figure 2) submissions. However, the supporting evidence, both in terms of written response and attached documents, does indicate that departments are now better able to provide evidence that supports the performance levels selected.

3.2.4. In addition, the 2015 questionnaire specifically asked departments whether their performance had improved or not. Most responses indicated that the performance had stayed the same, but there were many examples where departments had made real improvements since 2013, some of which are highlighted below.

3.2.5. The performance scores, although by no means an absolute indication of where the University currently sits, are beginning to show a more realistic assessment of the University’s overall performance, with a gradual level of improvement in some areas.

3.3. 2015 Self-Assurance Common Themes

3.3.1. Planning. The questionnaire asked “How does your department decide what actions to take to comply with health and safety legislation?”

3.3.2. Twenty-eight departments selected the top level performance (Level 3) in answer to this question, as opposed to thirty-two in 2013. This supports the idea that the standards across the University have at least been maintained. However, many

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departments identified specific improvements, such as countersigning local policies, training supervisors, improving communication of standards, or instigating an annual review of local documents against University health and safety policy statements.

3.3.3. Many of the written responses still spoke of simply distributing instructions and information, with limited follow-up or targeted action plans to ensure individuals fully understood and implemented the requirements. Indeed, within the 2015 Medical Sciences Division Health and Safety Review, this point was specifically noted with recommendations given to utilise departmental risk registers and general risk assessments to help ensure actions are completed.

3.3.4. Although the fundamental purpose of the self-assurance questionnaire is to help departments identify their own actions, it is clear that a greater steer from the University Occupational Health & Safety Service on these particular points would help with ongoing improvements across the University.

3.3.5. Rick Control. The questionnaire asked “How does your department conduct risk assessments and ensure that precautions and controls are adequate?

3.3.6. The performance scores and written statements indicate there is a good standard of risk assessments across the University. As in 2013, this is certainly true for the more general building related risk assessments, where the responses indicate they are more likely to be conducted by the departmental safety officers or the Oxford University Facilities Management team. For example, fire risk assessments were supplied for all departments, except one based abroad and one currently moving into a new building. Of the seventy-three departments covered by fire risk assessments, checks will be made on seventeen to ensure these have been reviewed in the past year.

3.3.7. Many departments identified improvements in the review process, either by the introduction of a formal review of all risk assessments each year or the use of risk assessment registers to help track when reviews or updates might be required. Certain departments also spoke of the need to ensure greater sign-off by supervisors and setting review dates at the time of the assessment.

3.3.8. The average performance score of 2.7 (out of 3) does not though match with the findings of individual HASMAP audits or divisional safety reviews. Indeed, individual returns highlighted the difference in the standard of general risk assessments, as opposed to topic specific risk assessments undertaken by individual groups or supervisors. This is an improving area with a number of departments reporting increased training of supervisors/assessors, and audit findings indicating that the coverage of risk assessments was generally good although lacking in sufficient detail in places. Further improvements should involve clarification of risk assessment standards for different hazards, followed by clear instruction and training to those who are expected to complete those assessments.

3.3.9. Arrangements. The questionnaire asked “How does your department establish and maintain management control?

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3.3.10.Departments are expected to complete a Statement of Safety Organisation to outline the managerial and advisory organisation in the department, and to update this document on a regular basis. To test this requirement, departments were again asked to supply a copy of their latest Statement of Organisation. The response (Figure 3) was around the same as that provided in 2013 (84% in 2015 v. 88% in 2013). Again checks will be made on the remaining departments to ensure they are either updated (11%) or completed (5%).

Figure 3: Percentage of departments submitting a Statement of Safety OrganisationPartially Provided

11%Not Provided

5%

Provided84%

3.3.11.The key point highlighted during the written evidence in 2015 related to the arrangements for health and safety of those working in other locations or departments.

3.3.12.Many departments highlighted the need for individuals to work in other departments or for their department to host other persons. This was particularly true for contractors, where again a number of departments raised concerns that contractors working under the auspices of the Estates Services, were able to enter their buildings without notifying them of the work they were planning to undertake. It is impossible to state how much of a risk this actually is, but the concerns are routinely raised by departments. As such, it would be appropriate for the forthcoming UAS Health and Safety Review to clarify whether this is a significant problem or not.

3.3.13.Another point that came up more in 2015 than in 2013, was the reliance on Estates Services Facilities Management to undertake various health and safety duties (e.g. risk assessment, inspections, emergency provision) on behalf of the department. In many areas this would seem entirely appropriate, but the written evidence by some departments would indicate an uncertainty over who is ultimately responsible, particularly where ‘Service Level Agreements’ have yet to be agreed. Again, the UAS Health and Safety Review could be used to help clarify any potential concerns.

3.3.14.Finally, at least four departments described improvements in their checks on the supervisory arrangements of other researchers coming into their department to use their equipment. This involved either discussions between the relevant departmental safety officers or more formalised systems where documents were completed

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outlining the formal supervisory arrangements before a department allowed them to use their equipment.

3.3.15.Co-operation. The questionnaire asked “How does your department consult with its members and encourage participation in developing health and safety procedures?”

3.3.16.University policy statement S2/01 states that all departments must provide a forum for the discussion of health and safety matters. As in 2013, departments provided evidence to indicate they had some forum where health and safety is discussed, be that a designated safety advisory committee or as an agenda item on another committee. There were few common concerns raised. Indeed, a number of departments reported improvements in this area by expanding the membership of their committees to provide greater opportunity for staff and student representation.

3.3.17.Competence. The questionnaire asked “How does you department identify training needs and ensure everyone is informed and suitably trained in health and safety procedures?”

3.3.18.This is an area where some individual departments have reported clear improvements, whilst all indicate at least a similar level of performance from 2013. The key improvements appear to be twofold:

Departments are beginning to develop and use training matrices and documented records to help ensure individuals are suitably trained. Some departments have undertaken a form of training needs analysis and although this does not automatically lead to mandatory training, departments have reported that it helps supervisors identify where training would be required. Two departments mentioned the use of ‘Personal Development Reviews’ where the head of department has asked supervisors to specifically consider health and safety training needs during that process. To further develop this across the University, examples from those departments currently using training matrices could be shared more widely in order to assist other departments.

Departmental safety officer training was noted as an improvement by a number of departments, principally where administrators have historically taken on the role. They report identifying new individuals to take on the role or attendance at the Safety Office’s training has occurred. Furthermore, twelve departmental safety officers completed a NEBOSH certificate course ran by the Safety Office in 2014, with another fourteen undertaking the same course in 2015 and at least two others reporting in their questionnaires that they joined the University with this level of training.

3.3.19.One aspect of the questionnaire that has caused confusion is in relation to job descriptions. The ‘Level 2’ statements says:

“Staff with key health and safety roles are provided with training or instruction. Job descriptions specify essential health and safety requirements. In addition, the

competence of staff is assessed prior to their appointment. The competence of

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students and [long-term] visitors is assessed at the earliest opportunity and before they are exposed to any hazard.”

As job descriptions do not specify health and safety requirements for all new jobs advertised, some departments state they are unable to select the higher performance level. That is a fair statement, but a key part of this is that many supervisor roles will also have health and safety requirements. It might not be necessary to outline specific health and safety requirements for all applications, as reference can simply be made to compliance with University policies. However, this statement should be clarified in order to help departments know when specific health & safety requirements might be needed in job descriptions, beyond those more general statements.

3.3.20.Incidents. The questionnaire asked “How does your department ensure incidents are reported, managed and investigated?”

3.3.21.This question recorded the highest average performance score of 2.73 (out of 3), which is also reflected in HASMAP audits. Departments do have systems for reporting accidents or cases of ill-health and this is widely known by members of those departments.

3.3.22.However, in terms of incident investigation fifty departments selected the ‘Level 3’ performance statement:

“Appropriate investigations are undertaken following incidents or cases of ill-health to identify corrective and preventative actions.  The investigations are prompted by the

supervisor, with support and advice taken from the safety officers.  The investigations consider by the immediate cause of the injury/illness, as well as the underlying

causes, such as supervision, training or resources.”

The key statement being “…investigations are prompted by the supervisor…” The written evidence to this question did not support this selection in many cases, as it was routinely stated that the departmental safety officer undertook the lead in investigations. This may not be a significant concern for many incidents, but it indicates a reliance on the safety officers to ensure appropriate actions are taken, rather than an integral part of the group’s research and planning. As such, it is possible that future planning of activities may not take into account any lessons learned from previous incidents.

3.3.23.Surveying. How does your department conduct inspections and ensure corrective and preventative measures are implemented?

3.3.24.Departments are expected to conduct an inspection of all areas each year. Departments were therefore asked to provide a copy of their inspection report. The response (Figure 4) was around the same as that provided in 2013 (65% in 2015 v. 67% in 2013). Again checks will be made on the remaining departments to ensure the findings are documented/submitted (23%) or completed (12%).

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Figure 4: Percentage of departments submitting an Inspection Report

Partially Provided

23%

Not Provided12%

Provided65%

3.3.25.Other than checking the completion rate, there were few common concerns raised. Indeed, a number of departments did report improvements in this area by ensuring inspections that had been outstanding were undertaken in the past year. Some departments also highlighted changes in their inspection teams or scheduling in order to better engage with supervisors/groups. Thus helping encourage individuals to identify their own concerns, rather than relying on the departmental or area/divisional safety officers to find problems.

3.3.26.Leadership. The questionnaire asked “How does your department ensure those with authority are committed to controlling risk and preventing harm to people?”

3.3.27.This question was again split into three parts, with no significant concerns highlighted over the ‘Head of Department’ and ‘Governance’ sections. However, as was the case in 2013, the specific section on ‘Supervisors’ scored the lowest overall average performance score [2.06 out of 3] with respect to a specific sub-question. This compares to 2.03 in 2013.

3.3.28.The common message from the written evidence is that supervisors are made aware of their responsibilities, but the extent to which they are actively implementing these varies within departments. Although some progress has been made in many departments with increased training and engagement by supervisors, the general feeling was the performance in this area is either at an adequate level or could be improved.

3.3.29.Emergency Planning and Response. The questionnaire asked “How does your department plan for health and safety emergencies and ensure people respond in an appropriate manner.

3.3.30.Each year, a ‘Key Topic’ is included in the questionnaire. In 2012 this was ‘Waste Handling and Liquid Nitrogen’ and in 2013, it was ‘Personal Protective Equipment’. In 2015 the ‘Key Topic’ was ‘Emergency Planning and Response’.

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3.3.31.The Emergency Planning and Response question was broken down into the following sections: General, Fire, Overseas Work & Travel, Hazardous Machinery or Equipment, and Hazardous Substances. For each section there was a series of ‘Yes’, ‘No’ or ‘N/A’ questions in order to identify how well University health and safety policy was applied, or indeed relevant. A full summary of the responses given to these questions is provided in Appendix B.

3.3.32.Once again it is difficult to identify any absolute themes from these responses, but there does appear to be a reasonable level of control in place to deal with emergency health and safety situations. The percentage of departments answering ‘Yes’ was always greater than 50% when taking the ‘N/A’ answers into account, indicating that emergency planning had been considered and systems were in place to help control the situation. There were a few areas of note though, that should be developed further:

General: Around a fifth of departments answered ‘No’ to the question: Do you have clearly defined and accessible contingency plans for dealing with a major fire, flooding, or any other serious foreseeable emergency (See University policy statement S5/01)? [24% of departments] In addition, the written evidence indicated that this was an area that was either being worked upon or needed closer attention. This is perhaps unsurprising as it is known that Oxford University Security Services are also in the process of encouraging departments to complete ‘Building Security Plans’ and ‘Emergency Action Plans’. It is likely that departments will need to consider all aspects of emergency planning in order to fully complete and outline their contingency plans. Sharing information learnt from this questionnaire should help steer departments into appropriate contingency plans for health & safety emergencies as part of that process.

Fire: The response to this section was good. The question that had the highest number of ‘No’ answers was: Is regular refresher training provided on fire procedures? [13% of departments] At present departments are not expected to run annual training sessions on fire procedures, other than ensuring suitable fire drills are undertaken. This area could be improved upon though, by ensuring individuals in the department are provided with feedback on their drills. In addition, those undertaking inspections could check individuals understanding of emergency fire procedures and supervisors could check the knowledge of those working alone or outside normal working hours before they undertook such activities.

Overseas Work & Travel: Of all the sections in the Emergency Planning and Response question, this gave the highest number of ‘No’ answers to a specific question: Have supervisors received a suitable level of training in order to assess the suitability of contingency plans as part of the risk assessment approval process? [29% of departments] Indeed, if we ignore the number of departments answering ‘N/A’ to this question, the percentage of departments answering ‘No’ to this question was 42%.

Fieldwork training has certainly increased since 2013. Not only are departments utilising the central Safety Office run courses, but departments and faculties in Social

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Sciences and Humanities have started to run their own training sessions. This appears to have increased the attendance as the training is strongly encouraged (or expected in some cases) and is seen more relevant to the specific needs of the department. However, the response to this question would indicate a need to check whether the level of fieldwork supervisor training undertaken across the University is sufficient and specifically, whether the training itself needs to provide more information on contingency planning or dealing with potential emergencies whilst travelling abroad.

Hazardous Machinery & Equipment AND Hazardous Substances: Again, the response to both these sections was good. The only questions that gave the highest number of ‘No’ answers in both sections related to specialist first aid training or instruction, not only to provide relevant first aid, but to deal with an emergency should it arise e.g. entrapment within workshop machinery. Again, this is an area that has already been highlighted during recent HASMAP audits. It has also been noted that first aid for hazardous substance exposures is no longer covered during standard first aid at work courses. It is therefore a potential training area that could be developed within the University to supplement the external first aid training.

3.3.33.Integration. The questionnaire asked “How does your department ensure health and safety is seen as an integral part of the department's overall objectives and decision making?

3.3.34.The main purpose of this question is to ensure the health and safety implication of new building projects or activities are considered at a suitable stage. The responses all indicate that this is considered to be the case, with no areas for improvements identified as departments were satisfied with the performance level selected.

3.3.35.Of particular note though, was the second part of the question where only fifteen departments selected the ‘Level 3’ statement:

“Documented plans for improving health and safety performance exist, clearly defining objectives according to an assessed level of risk. These plans are

understood by senior management and monitored to help the department strive for continuous improvement in health and safety performance.”

3.3.36.This matches the written evidence given for this question, as only five departments formally stated that they had developed an action plan to take forward any gaps identified during the questionnaire. Many departments stated that these issues would be discussed and taken forward by the relevant safety committee, which is reasonable, but this may limit the decision making of senior management when deciding where to allocate resources against the research and teaching needs.

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4. HEALTH & SAFETY MANAGEMENT PROFILE (HASMAP) AUDITS

4.1. HASMAP Audits Completed

4.1.1. Three departments (Figure 5) were audited in 2015. The HASMAP standards were also used to examine the health and safety performance of the Medical Sciences Division during their divisional review in 2015.

Figure 5: HASMAP Audits conducted between January 2015 and December 2015Department Date of Audit AuditorsLudwig Institute for Cancer Research 15th, 16th, 21st and 24th April 2015 Tanya Boyce

Brian JenkinsSir William Dunn School of Pathology 17th and 20th April 2015 Julie Black

Brian JenkinsThe Kennedy Institute of Rheumatology

8th, 10th, 13th, 14th and 23rd July 2015

Tanya BoyceBrian JenkinsTracey Mustoe

4.1.2. This brings the total number of departments audited since the introduction of the University policy on HASMAP audits, in 2009, to thirty-one (Figure 6).

Figure 6: Number of HASMAP audits completed to date across Divisions

4.1.3. In 2016 HASMAP audits will be conducted in University Administration and Services (UAS) as part of their health and safety review.

4.2. HASMAP Performance

4.2.1. The average performance levels identified during HASMAP audits are lower than the average performance levels selected by individual departments during the 2015 self-assurance exercise (Figure 7). This might be expected given the simplified nature of the self-assurance questionnaire and taking into account any improvements made by departments since the initial audits. However, the data from both sources indicates that departments generally perform at around Level 2 to Level 3 with respect to the

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HASMAP standards. This indicates that departments have a structured and systematic approach to the management of health and safety, although the health and safety management system may not be fully embedded and in some areas its effectiveness in identifying and controlling risk may be limited.

Figure 7: Comparison of the Average HASMAP scores from the thirty-one audited departments against the 2015 Self-Assurance scores

4.2.2. Common recommendations highlighted during the 2015 audits were:

Need for improvements in risk assessment review process, particularly for high risk equipment and hazardous substances.

Need for improvements in supervisors’ knowledge of University policy and their implementation at a local level.

Clarification of shared supervisor responsibilities, such as the use of shared facilities within a single building, or where staff or students collaborate and work in other departments.

Need for improvements in training, particularly with respect to competency requirements for higher risk activities and record keeping.

4.3. Updates to the University Sector Guidance - Leadership and Management of Health and Safety in Higher Education Institutions – and HASMAP Standards.

4.3.1. At the Higher Education sector’s University Safety and Health Association (USHA) Autumn Conference in October 2015, the new ‘Leadership and Management of Health & Safety in Higher Education Institutions’ guidance was launched. This updates a previous UCEA guidance document, making it easier to interpret and to reflect the principles set out in the Health & Safety Executive’s own updated guidance

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‘HSG65 - Managing for health and safety’. A summary of the management tiers set out in the USHA guidance are outlined in Appendix C.

4.3.2. To support the launch of the updated guidance, USHA also took the opportunity to update and improve the sector’s HASMAP standards. Many of these changes are simply to make it easier and clearer to use, in order to help auditors with different levels of experience to use the standards and assess their university. It also enables an auditor to pick and choose certain indicators to audit against, rather than completing a full audit on each occasion. This greater flexibility will help, not only to enable more frequent audits, but will help the University target which particular indicators (e.g. Leadership, Planning for Emergencies, Health and Safety Arrangements, Risk Assessment and Risk Control, Competence, Communication, Consultation, Health and Safety Monitoring, Accidents and Incidents, and Review) it feels are most important or relevant.

4.3.3. One of the key changes to the new guidance though, is the removal of numbered performance levels (i.e. Level 0, 1, 2, or 3 or 4, as noted in Section 3.2.1) and to replace this with just three clear assurance statements; Basic, Substantial and High (Figure 8).

Figure 8: Assurance statements from the Higher Education 2015 HASMAP Standard

4.3.4. As already indicated, University policy statement S1/11 on HASMAP states that a department is expected to achieve Level 3 in each indicator. In terms of the new updated ‘2015’ HASMAP standard, this would automatically translate to departments working towards a ‘Substantial’ level of assurance in their health and safety management systems. Indeed, from an initial review of the updated 2015 HASMAP standards, many of the departments should automatically fit into the ‘Substantial’ assurance level, but this would need to be tested.

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4.3.5. The process also gives a clearer steer to those departments wishing to go for external health & safety accreditation, such as the soon to be introduced international standard ‘ISO 45001 - Occupational Health and Safety’.

4.3.6. Overall, both the updated guidance and ‘2015’ HASMAP standards offer benefits to the University in helping heads of department to develop their health and safety management systems. This will be important not only as it will help reduce the likelihood and seriousness of accidents, but helps reduce any potential enforcement action as good health and safety management can be demonstrated. The committee is therefore asked to endorse the move away from the 2007 HASMAP audit standards and to use the updated 2015 HASMAP standards as its benchmark for assessing University performance. If this is agreed, then work will be done over the forthcoming year to trial and implement this process.

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5. AREAS FOR DEVELOPMENT

5.1.1. As before, the self-assurance exercise is ultimately aimed at supporting departments, with an expectation that any gaps identified during the process will be taken forward by the department themselves. However, the review has identified a number of areas that should be developed at a University level as well. It is not possible at this stage to define exactly how all these points will be addressed, but the University Occupational Health & Safety Service will formulate a more detailed action plan once the new Director is in position. This will be brought back to the next committee for confirmation and ongoing discussion.

Area for Development SectionEncourage completion of the 2015 self-assurance questionnaire from those departments yet to submit.

3.1.2

Provide guidance on how health and safety matters could be included in risk registers or departmental risk assessments, in order to help prioritise actions and resources by senior departmental management.

3.3.3

Follow-up on fire risk assessments, statements of safety organisation, safety committees, and inspection reports to ensure these are in place for all departments.

3.3.63.3.103.3.24

Provide further clarification and guidance on risk assessment standards for differing hazards, followed by clear instruction and training to those who are expected to complete those assessments.

3.3.8

As part of the forthcoming UAS Health & Safety Review assess the risks associated with departmental concerns over contractors entering their buildings but working under the auspices of the Estates Services.

3.3.12

As part of the forthcoming UAS Health & Safety Review check the health & safety arrangements and responsibilities where departments occupy buildings supported by Estates Services Facilities Management.

3.3.13

Identify examples of Best Practice amongst departments in terms of training needs analysis, training matrices and training records. Share this information with other departments as an indication of how health and safety training could be further developed.

3.3.19

Provide guidance on when specific health and safety requirements should be included in job descriptions.

3.3.20

Review the level of fieldwork training undertaken by relevant supervisors. Assess whether further changes are required to the implementation of this training or the training itself to ensure appropriate contingency plans are implemented for those travelling abroad.

3.3.33

Check with departmental safety officers whether there is a specific need to run specific first aid for chemical or machinery accidents across the University.

3.3.33

Follow-up via area and divisional safety officers to ensure departments do discuss their self-assurance questionnaires during safety committee meetings and that appropriate action plans are established.

3.3.37

Update University policy statement S1/11 to outline how the new ‘2015’ HASMAP standards would be used across the University.

4.3.6

BJ/BJ

22/2/2015

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Appendix A – Average 2015 health & safety self-assurance performance scores for each question by Division.

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Appendix B – Answers to the specific sub-questions in Q.9 Emergency Planning & Response of the 2015 H&S Self-Assurance

1. GeneralNumber Question Percentage (%) of Departments

Answering:Yes No N/A

1.1 RISK ASSESSMENT: Have you examined your accident or incident data, as well as any reported cases of ill-health, in order to identify your first aid requirements (see 'Assessment of First Aid Needs (UPS S4/14)')?

84 11 5

1.2 RISK ASSESSMENT: In addition to injuries or illnesses, health and safety accidents include damage to equipment / building (e.g. equipment faults or misuse, collapse of storage units and shelving, floods, electrical faults, lifting gear failures, sudden release from pressure vessels). Do your risk assessments consider these types of events?

65 28 7

1.3 RISK ASSESSMENT: Does the department assess the need for additional first aid or emergency provision when individuals work alone or outside normal hours (see University policy statement S5/08)?

73 15 12

1.4 RISK ASSESSMENT: Do your risk assessments consider the impact of non-routine service or maintenance work [by contractors or staff] on your emergency procedures (see University policy statement S6/08)?

69 20 11

1.5 PROCEDURES: Do you have systems in place for checking first aid provision, including equipment and the competence of first aid personnel?

92 3 5

1.6 PROCEDURES: Do you have clearly defined and accessible contingency plans for dealing with a major fire, flooding, or any other serious foreseeable emergency (See University policy statement S5/01)?

71 23 7

1.7 PROCEDURES: Have you provided an up to date list of ‘Key Holders’ to the Oxford University Security Services?

76 9 15

1.8 TRAINING: Do you check individuals' knowledge of emergency procedures during discussions or inspections?

79 16 5

1.9 TRAINING: Are those working alone or outside normal working hours been given adequate instruction and training in how to respond to a foreseeable incident?

83 9 8

1.10 POST-EVENT: Does the department have suitable systems in place to ensure first aid or emergency equipment is replaced after it has been used?

93 3 4

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2. FireNumber Question Percentage (%) of Departments

Answering:Yes No N/A

2.1 RISK ASSESSMENT: Have you reviewed the fire risk assessment within the past year? 83 11 72.2 RISK ASSESSMENT:  Have you reviewed the fire risk assessment since the last significant

change to the building?65 1 33

2.3 RISK ASSESSMENT:  Have the significant findings from the fire risk assessment been addressed?

63 1 36

2.4 RISK ASSESSMENT:  Where actions arising out of the fire risk assessment have not been addressed, have they been incorporated into an action plan to address any deficiencies in a timely manner?

40 4 56

2.5 PROCEDURES:  Are written procedures in place to evacuate the building in case of fire? 92 5 32.6 PROCEDURES:  Have specific tasks been clearly designated so that all staff are aware of

their role in an evacuation?95 0 5

2.7 TRAINING:  Is regular refresher training provided on fire procedures? 83 13 42.8 TRAINING:  Have fire drills been carried out as required in University policy statement

S8/07 and records kept?91 7 3

2.9 TRAINING:  Have those with designated fire response tasks (e.g. interrogation of fire panel, assisted evacuation of others, relaying information to emergency services, control of evacuation) been given additional training/instruction (including deputies)?

88 4 8

2.10 POST-EVENT:  Are the arrangements for reporting, recording, and investigating fire incidents known and followed?

83 9 8

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3. Overseas Work and TravelNumber Question Percentage (%) of Departments

Answering:Yes No N/A

3.1 RISK ASSESSMENT:  Are the risks associated with overseas travel suitably assessed in order to identify appropriate contingency plans?

72 5 23

3.2 RISK ASSESSMENT:  Are travel risk assessments, covering higher risk activities or   countries , provided to the department in a reasonable time, so that contingency plans can be reviewed and checked?

56 8 36

3.3 RISK ASSESSMENT:   Are written risk assessments prepared, approved by the head of department, and submitted to the University Safety Office, in a reasonable time, whenever the proposed travel includes locations that the Foreign & Commonwealth Office have advised against (see University policy statement S3/07)?

44 8 48

3.4 PROCEDURES:  Are systems in place to check that a traveller has access to appropriate emergency provisions, as identified during their risk assessment (e.g. first aid, medical provisions, mobile phone, satellite phones, spare documents, emergency contact information, rescue equipment, water, food, clothing etc.)?

55 12 33

3.5 PROCEDURES: Does the department have a way of identifying and contacting those staff or students who are “in country” in an emergency?

67 5 28

3.6 TRAINING: Does the department check that individuals are conversant in the emergency procedures, for all foreseeable emergencies, prior to travelling?

47 25 28

3.7 TRAINING: Have supervisors received a suitable level of training in order to assess the suitability of contingency plans as part of the risk assessment approval process?

41 29 29

3.8 TRAINING:  Where risk assessments identify departmental staff as emergency contacts, are checks carried out to ensure contact details are up to date and that these individuals understand the actions they are expected to take should an accident or illness occur?

49 16 35

3.9 POST-EVENT: Are work-related accidents, incidents or illnesses that occur during overseas travel reported to the University Safety Office?

57 5 37

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(HSJC(16)06)

4. Hazardous Machinery or EquipmentNumber Question Percentage (%) of Departments

Answering:Yes No N/A

4.1 RISK ASSESSMENT:  Have risk assessments been conducted for hazardous machinery or equipment [including those items used by facility, workshop, laboratory, estates or parks' staff] to identify the likelihood of a physical injury occurring?

55 4 41

4.2 RISK ASSESSMENT:  Do risk assessments for hazardous machinery or equipment identify appropriate emergency procedures for dealing with physical injuries, such as manual handling injuries, contact with moving parts, impact with flying objects, electric shock, thermal burns, pressure system failures, or laser eye exposures?

43 12 45

4.3 RISK ASSESSMENT:  Does the department assess the ability of individuals to deal with a hazardous machinery incident prior to them being permitted to operate machinery alone?

51 3 47

4.4 PROCEDURES:  Where identified in risk assessments, are there clear and easily accessible emergency devices to stop, isolate and make-safe hazardous equipment or machinery?

49 4 47

4.5 PROCEDURES:  Does the department ensure appropriate tests are conducted on emergency devices, such as emergency stop buttons, alarm systems, warning signs, guarding?

51 3 47

4.6 TRAINING:  Is the knowledge of individuals to be able to stop and make-safe hazardous machinery or equipment checked during discussions or inspections?

43 11 47

4.7 TRAINING:  Have first aiders, or anyone else who might need to respond to a hazardous machinery or equipment incident, been given appropriate training or instruction on how to make-safe the area before treating an injury?

35 19 47

20

(HSJC(16)06)

5. Hazardous SubstancesNumber Question Percentage (%) of Departments

Answering:Yes No N/A

5.1 RISK ASSESSMENTS:  Do COSHH risk assessments identify suitable procedures for dealing with an accidental release, exposure or spillage?

55 4 41

5.2 RISK ASSESSMENT:  Does the department assess the ability of an individual to deal with an accidental release, exposure or spillage before allowing them to handle hazardous substances outside normal working hours?

41 11 48

5.3 PROCEDURES:  Is there clear information or signage available for non-departmental staff (e.g. University Security Services, Emergency Services, University Estate's Services, Hospital Trust Estate's Services) highlighting the location of any hazardous substances that might pose them a significant risk?

55 1 44

5.4 PROCEDURES:  Is the University's 'Immediate action after exposure to infectious material'  sign displayed in all places where exposure to potentially infected material might occur (see University policy statement OHS 2/03)?

21 7 72

5.5 TRAINING:  Have those working with hazardous substances been trained in the emergency procedures, as outlined within individual COSHH risk assessments?

49 9 41

5.6 TRAINING:  Where COSHH risk assessments identify a specialist first aid response, have first aiders been given appropriate training or instruction (e.g. hydrofluoric acid, cyanide poisoning, phenol burns)?

28 16 56

5.7 TRAINING:  Has appropriate training been given to those individuals handling hazardous substances outside working hours, so they are able to manage an accidental release, exposure or spillage?

36 5 59

5.8 TRAINING:  Have support staff, including reception and building services staff, been given any training and instruction on how to contact and inform the emergency services of a hazardous substance incident?

39 13 48

5.9 POST-EVENT:  Does the department hold appropriate waste containers and equipment (including personal protective equipment) in order to safely collect and dispose of a hazardous substance, following any accidental release or spillage?

34 4 47

21

(HSJC(16)06)

Appendix C – Summary of the Management Tiers as described by USHA’s new Leadership and Management of Health and Safety guidance.

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