The Health and Safety Executive in Guernsey (HSE) is the regulator for workplace health and safety and works with other States of Guernsey services to make sure hospitals, care homes and other healthcare activities are safe and healthy for their workers, patients, service users and the public.
- There are additional measures in place for COVID-19 risks known as Transmission-Based Precautions (TBPs) depending on the route of transmission of the infectious agent:
- Contact precautions: Used to prevent and control infection transmission via direct contact or indirectly from the immediate care environment (including care equipment). This is the most common route of infection transmission.
- Droplet precautions: Used to prevent and control infection transmission over short distances via droplets (>5μm) from the respiratory tract of one individual directly onto a mucosal surface or conjunctivae of another individual. Droplets penetrate the respiratory system to above the alveolar level. The maximum distance for cross transmission from droplets has not been definitively determined, although a distance of approximately 2 metres (6 feet) around the infected individual has frequently been reported in the medical literature as the area of risk. However, a precautionary approach is recommended and close contact has been defined as within 2 metres (approximately 6 feet) of a patient.
- Airborne precautions: Used to prevent and control infection transmission without necessarily having close contact via aerosols (≤5μm) from the respiratory tract of one individual directly onto a mucosal surface or conjunctivae of another individual. Aerosols penetrate the respiratory system to the alveolar level. Interrupting transmission of COVID-19 requires both droplet and contact precautions; if an aerosol generating procedure (AGP) is being undertaken then airborne precautions are required in addition to contact precautions.
- In addition to SICPs, droplet precautions should be used for patients known to be or possibly infected with COVID-19 in all healthcare settings.
- COVID-19 virus is expelled as droplets from the respiratory tract of an infected individual (for example during coughing and sneezing) directly onto a mucosal surface or conjunctiva of a susceptible individual(s) or environmental surface(s)
- droplets travel only short distances through the air; a distance of at least 2 metres has been used for deploying droplet precautions; however, this distance should be considered as the minimum rather than an absolute
- Please follow this link for guidance on PPE and RPE for healthcare workers during the COVID-19 pandemic.
Risks of infection in healthcare
- Healthcare workers are a key risk group because of the nature of their work. HSE do not have accurate data on infections and ill health in this group - but data from physician reporting schemes indicates infection rates of about 30 per 100 000 workers per year amongst nurses and about 100 per 100 000 per year amongst care givers in residential homes. Most of these infections are diarrheal diseases. However, more serious infections do sometimes occur. For example, four health workers have died after having accidentally incurred needlestick injuries during work with HIV patients.
- Healthcare-associated infection (HAI) is an important cause of morbidity and mortality amongst hospital patients, especially with the increasing resistance of many human pathogens to antibiotics (e.g. methicillin-resistant Staphylococcus aureus: MRSA). However, the HSE do not generally deal with clinical matters as these are more appropriately dealt with elsewhere. One exception to this is where there are management failures or failures of systems of work and in such cases HSE do sometimes become involved.
- The Standard Infection Control Precautions (SICP) are the appropriate standard in Guernsey and includes:
- patient placement/assessment for infection risk
- hand hygiene
- respiratory and cough hygiene
- personal protective equipment (PPE)
- safe management of care equipment
- safe management of the care environment
- safe management of linen
- safe management of blood and body fluids
- safe disposal of waste (including sharps)
- occupational safety/managing prevention of exposure (including sharps).
Personal Protective Equipment (PPE) and Respiratory Protective Equipment (RPE)
- Employers have a duty to provide personal protective equipment (PPE) and respiratory protective equipment (RPE) at work, where the risk assessment shows that it is necessary to protect against the risk.
- PPE is equipment that will protect the user against health or safety risks at work. It can include items such as gloves, safety helmets, gloves, eye protection, high-visibility clothing, safety footwear and safety harnesses. It also includes RPE such as respirators and fluid-repellant surgical masks.
- Before undertaking any procedure, staff should assess any likely exposure to bioaerosols, blood and/or other body fluids, non-intact skin or mucous membranes and wear PPE that protects adequately against the risks associated with the procedure.
- All PPE should be:
- located close to the point of use
- stored to prevent contamination in a clean, dry area until required for use (expiry dates must be kept to)
- single-use only items unless specified by the manufacturer
- changed immediately after each patient and/or after completing a procedure or task
- disposed of after use into the correct waste stream, ie healthcare waste or domestic waste.
- Reusable PPE items - eg non-disposable goggles, face shields, visors - must be decontaminated after each use.
Sensible risk assessment in care settings
- Guernsey care providers must be registered with the Committee for Health and Social Care.
- People who work in health and social care constitute a large and diverse workforce looking after a predominantly vulnerable population. Employees have the right to work in a healthy and safe workplace, and the people using services are entitled to care and support that is safe and takes their needs, freedom and dignity into account.
- Managing these different needs can sometimes present unique and complex situations which can, if not effectively managed, result in serious harm to employees, people using care services and others. The typical hazards include:
- Whilst specific hazards to people using care services may also include:
- The risk assessment process is not about creating huge amounts of paperwork; it is about identifying and taking sensible and proportionate measures to control the risks. You may already be taking steps to control the risks, but the assessment process will help you decide whether you should be doing more. You may need to consider different elements of risk when producing your assessment, including:
- the common risks to everyone on the premises, for example, risks from legionella, asbestos, electrical equipment and transport
- the common risks to people using services, for example, from falls from height or scalding. Whilst you may have some individuals who are not at risk you must implement measures to prevent harm to the most vulnerable
- the individual risks to particular staff, for example expectant mothers and young workers
- the individual risks to particular people using services, for example the risk of an individual falling out of bed, or needing help to safely mobilise
- When considering the individual risks for particular people using a service, you must also bear in mind that health and social care is regulated by other organisations who may expect some form of care assessment. Usually the health and safety risks identified for the individual will be recorded as part of this 'care assessment' or 'support plan'.
Making sensible risk assessment decisions
- The provision of care and support should be tailored to meet the needs of the individual and should encourage them to do what they can for themselves. This is particularly important in the provision of social care but also applies to people receiving longer-term healthcare.
- Often when assessing the care and support needs of an individual, everyday activities are identified that will benefit their lives, but also put them at some level of risk. This requires a balanced decision to be made between the needs, freedom and dignity of the individual and their safety.
- Care assessments should enable people to live fulfilled lives safely, rather than be a mechanism for restricting their reasonable freedoms. Many care providers find it hard not to slip towards a risk adverse approach for a multitude of reasons, for example, resources, bad experiences and a fear of the consequences if things go wrong.
- HSE will support decisions to allow everyday activities to be undertaken provided a suitable and sufficient risk assessment has been carried out, documented and reviewed as necessary. This should identify and implement any sensible precautions to reduce the risk of significant harm to the individual concerned (see examples below).
Key points to consider when balancing risk include:
- Concentrating on real risks where there is a realistic risk of harm
- Close liaison with the individual, carer and family when carrying out risk assessments which is essential to achieve outcomes that matter to them
- How the risks flowing from an individual's choice can best be reduced, so far as is reasonably practicable, by putting in place sensible controls
- When organising group activities, think how the most vulnerable can be protected without unnecessarily restricting the freedoms of the most capable.
Domiciliary care provided in people's own homes
- Increasingly, care is provided within people's homes by Personal Assistants (PAs), care agency staff, HSC homecare services or district and community nurses.
- The risks to both those being cared for and those providing the care, will vary greatly according to the individual's needs, the environment where care is provided, the type of care being provided and the competence of the carer.
Does the Health and Safety at Work Act 1974 (HSWA) apply to care provided in people's homes?
- Health and safety legislation does not normally apply to activities classed exclusively as 'domestic services' carried out in 'private households.'
- Personal care provided within someone's own home by a live-in carer, family member or housekeeper is likely to be 'domestic service' and therefore may fall within this dis-application.
- Whether the Health and Safety legislation dis-application applies in specific circumstances will need to be considered on a case by case basis (and be subject to careful legal interpretation), but as an indicative guide:
- if the carers work for HSC, Primary Care, care agencies or employment agencies then they are unlikely to be employed exclusively as domestic workers and Health and Safety legislation will apply,
- if the care involves complex healthcare activities (such as operation of life support or palliative care equipment) then Health and Safety legislation is likely to apply, and,
- if delivery of the care requires specialist training (for example, people handling and dealing with challenging behaviour) then Health and Safety legislation is likely to apply.
What accidents and incidents will HSE investigate
- HSE sets out its overall public safety policy [742kb] and priorities for enforcement [362kb] on the GOV.GG website. In general we will only investigate where:
- The accident or incident is reportable under the Section 9 of the Health and Safety at Work (General) (Guernsey) Ordinance, 1987 - Reporting of Injuries Diseases and Dangerous Occurrences and meets our investigation criteria. These tend to include major non-clinical accidents such as trips and falls, scalding and those arising from people handling; or
- The accident or incident is not reportable, but has clearly been caused by well established standards not being achieved and the failure to meet them arises principally from a systemic failure in management systems.
- We will only investigate such incidents where a death has occurred, or where the harm was so serious that death may have resulted; and where admissible evidence is likely to be available
- The 'established standards' that HSE will consider, in deciding whether investigation is appropriate, include:
- widely recognised, followed and expected practices for dealing with a particular issue; or
- States of Guernsey HSC, NHS, UK Department of Health or other 'safety alerts', or similar warnings, that are widely known across the sector; or
- duty holder's (ie healthcare providers) internal guidance, or well established external guidance from others, where this addresses issues that fall within HSE's broader selection criteria.
- 'Established standards' will not, in general, include those which cover:
- the standard of care or treatment, such as those dealing with the types of drugs or approach that might be appropriate; or
- 'quality of care' issues, such as those dealing with hydration or nutrition.
- Systemic failures in management systems may include:
- absence of, or wholly inadequate, arrangements for assessing risks to health and safety;
- inadequate control of identified, or well recognised, health and safety risks; or
- inadequate monitoring, or maintenance, of the procedures or equipment needed to control the risk
- In general, we will not investigate where:
- the incident arises from poor clinical judgement (rather than a failure to implement the actions flowing from clinical judgements);
- the incident is associated with 'standards of care', such as the effectiveness of diagnostic equipment; or the numbers and experience of clinicians;
- the incident is associated with quality of care, such as hydration and nutrition; or
- the incident arose from the disease or illness for which the person was admitted, (whether or not that disease was properly diagnosed or treated) - unless the prime cause was inadequate maintenance of, or training in the use of equipment needed to treat the disease or illness; or otherwise falls within the criteria set out above, or the worked examples given below.