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General Policy
To Be Categorised
Health & Safety Manager
Health & Safety Manager
Director of Property & Asset Management
01 November 2016
01 February 2022
01 February 2025
Version 3

General Note

NHS Fife acknowledges and agrees with the importance of regular and timely review of policy statements and aims to review policies within the timescales set out.

New policies will be subject to a review date of no more than 1 year from the date of first issue.

Reviewed policies will have a review date set that is relevant to the content (advised by the author) but will be no longer than 3 years.

If a policy is past its review date, then the content will remain extant until either such time as the policy review is complete and the new version published, or there are national policy or legislative changes.


1.1  NHS Fife has a duty of care to ensure the health, safety and welfare of staff  employed by NHS Fife and all persons (eg patients, visitors, contractors etc)  liable to be affected by the activities of the organisation.

1.2  This policy has been prepared to comply with the organisation’s duties under  Section 2(3) of the Health and Safety at Work etc Act 1974 [The Act].

1.3  Further policies and procedures made under this policy fulfil the organisation’s  duties under The Act and subordinate legislation.


2.1 Location

2.1.1  The policy applies across all areas of NHS Fife and the Fife Health and Social  Care Partnership where staff are undertaking work activity on behalf of the  organisation including off-site premises, public locations and domiciliary  settings.

2.2  Scope

2.2.2  This policy applies to all staff and, by agreement, with independent contractors  working within, or on behalf of, NHS Fife.


3.1 Chief Executive

3.1.1 The Chief Executive has overall accountability for ensuring that the  organisational structure, arrangements and resources exist to implement this  policy, its objectives and associated plans.

3.1.2 The Chief Executive will also agree and sign the NHS Fife Health and Safety  Policy Statement [Ref 6.1 Appendix 1].

3.2  NHS Fife Board

3.2.1 The Board is responsible for ensuring that NHS Fife complies with all the  relevant standards inclusive of those related to health & safety.

Authority is delegated to the NHS Fife Health and Safety Sub Committee which is required to provide regular reports to the Board, via the Clinical Governance Committee, on work undertaken.

The governance structure for Health and Safety is noted in the NHS Fife & Fife Health and Social Care Partnership H&S Governance Structures [Ref 6.2 Appendix 2].

3.3  Directors (including Director of Property and Asset Management)

3.3.1  Directors are responsible for the safety and activities of their staff and are  expected to promote a high degree of health and safety leadership and  awareness.

3.3.2  In accordance with Regulation 7 of the Management of Health and Safety at  Work Regulations 1999, the Director of Property and Asset Management will  appoint competent health & safety advisors to ensure health and safety  assistance is provided for all employees.

3.3.3  The Director of Property and Asset Management also has the responsibility to  oversee health and safety within NHS Fife and will report any known significant  organisational failings to the Chief Executive.

Many of the duties arising from this responsibility are delegated to senior managers, line managers and to the Health and Safety Manager.

3.4 Heads of Service/ Department/ Service Managers/ General Managers, etc  (hereafter referred to as ‘Senior managers’)

3.4.1  Senior managers are responsible for implementing suitable and sufficient  arrangements to ensure, so far as is reasonably practicable, the health, safety  and welfare of their staff, service users and visitors.

3.4.2  The duties of line managers noted below also apply to Senior managers.

3.5 Senior Charge Nurses/ Midwives, Heads of Department, Team Leaders,  Supervisors, etc (hereafter referred to as ‘line managers’)

3.5.1  Line managers must, so far as is reasonably practicable, provide a safe working  environment, safe systems of work and support and implement policies and  procedures which will underpin this policy.

3.5.2  Line managers must assess the health and safety risks to employees and other  persons within their area of responsibility, identify measures to reduce the level  of risk, and introduce controls to ensure the risk is managed appropriately.  

Line managers can appoint risk assessors within their departments to undertake and record the risk assessment. However, implementing necessary actions to reduce risks and review of existing risks remains the responsibility of the manager.  

3.5.3  Line managers are responsible for ensuring that employees receive information  and instruction in safe working methods and potential risks and for identifying  the appropriate level of health and safety training required by their staff.

3.5.4 Line managers are responsible for ensuring that all new employees are given  work-based health and safety instruction and the details must be recorded. This  will include instruction on fire and evacuation procedures.

3.5.5  Line managers will ensure that local health and safety management  arrangement documents are introduced which address specific operational and  organisational health and safety risks within their area of responsibility.

3.5.6  Line managers will monitor the implementation of local arrangements and  prepare and implement local health and safety action plans.

3.6 Employees

3.6.1  Employees are required to:

• Take reasonable care to ensure the health and safety of themselves and others who may be affected by their acts or omissions.
• Co-operate with managers to ensure compliance with policy, procedural and statutory requirements.
• Ensure that items provided in the interests of health and safety are not intentionally or recklessly interfered with.
• Report any perceived danger of unsafe working practices or conditions to their appropriate supervisor, manager or staff side representative.
• Be aware of emergency procedures, including evacuation and fire precaution arrangements for their area of work.
• Notify all hazards, defects, accidents and incidents, including near misses, to their line manager or supervisor and follow the organisation’s incident reporting procedures.
• Undertake safety and risk management training where identified as a learning need or mandatory training requirement.

3.7 Contractors

3.7.1  Contractors carrying out work on NHS Fife premises are expected to comply  with health and safety legislation, this policy, the NHS Fife Control of  Contractors Policy procedures/general-policies/control-of-contractors-equipment-building- maintenance and any relevant service or department procedures.

3.7.2  The person supervising the award of any contract must ensure that the  contractors are aware of their health and safety responsibilities and specify  detailed health and safety performance requirements in a written term of  agreement.

3.8  Health and Safety Committee / Forum

3.8.1  Within the Acute Division & Corporate Directorates a Health & Safety  Committee and a Health & Safety Assurance Group in the Health & Social Care  Partnership will be responsible for the operational overview of health and safety  issues within their areas. These groups will provide a direct link to the NHS Fife  Health and Safety Sub Committee to ensure that strategic priorities are  addressed.

3.9 NHS Fife Health & Safety Team

3.9.1  The NHS Fife Health and Safety Team provide support for general health &  safety, manual handling and violence & aggression matters.

3.9.2  The NHS Fife Health & Safety Team are responsible, through the Health &  Safety Manager for:

• Delivering a suitable Health & Safety Management system for NHS Fife including review and update of the Health and Safety Management Assistant Workbooks.
• Providing necessary training, advice and support to staff and managers.
• Providing strategic direction for health & safety.
• Supporting Health and Safety Committees, groups and other relevant meetings.
• Promoting a positive health & safety culture.
• Supporting the organisation in achieving legislative compliance.
• Development and review of health & Safety related policies and procedures.
• Any other relevant objectives as set by Director of Property and Asset Management.

3.9.3  In addition, the Health and Safety Manager is point of contact for Health and  Safety Executive Inspectors.


4.1 NHS Fife will continue to develop and foster a culture which regards health and  safety management as an integral part of the organisation’s general management arrangements.

4.2 Consultation with Employees

4.2.1  NHS Fife will provide effective arrangements for partnership working for all  matters relating to health and safety.

4.2.2  NHS Fife is committed to working in partnership with Health and Safety  Representatives both as part of its organisational health and safety  arrangements but also at a local level when addressing specific issues.

4.2.3 Health and safety representatives will be invited to participate on all health and  safety committees.  In addition, NHS Fife will ensure that any representative  receives adequate facilities and arrangements to undertake this key role.

4.3 Local Health and Safety Management Arrangements

4.3.1 Local Health and Safety Management Arrangements are implemented in NHS  Fife through the Health and Safety Management Assistant Workbooks  (hereafter referred to as the H&S Workbook).

4.3.2  H&S Workbook holders will normally be line managers. If H&S Workbook  holder for an area is not a line manager, their role is to support the manager in  fulfilling their H&S obligations. Responsibility for ensuring that H&S is  appropriately managed always sits with the line manager, regardless of  whether or not they are the H&S Workbook holder.

4.3.3  H&S Workbooks are issued by the Health & Safety Team. The H&S Workbook    acts as a source of information regarding responsibilities and as a record on  how these responsibilities are to be discharged.

4.3.4  The H&S Workbook is a working document and its format and use will be  regularly reviewed to reflect current practice and legislation. Senior and Line  managers are responsible for keeping their copy updated.

4.3.5  H&S Workbook holders are expected to:

• Co-ordinate and supervise on health and safety matters within their designated areas.
• Form a link and point of contact for members of the organisation, specialist advisers and members of staff.
• Develop management systems and action plans which they will monitor and review regularly.
• Support line managers in the appointment of suitable risk assessors.
• Support line managers by ensuring that risk assessments are carried out and that appropriate action is taken to control identified risks.

4.4  Training

4.4.1 NHS Fife recognises the importance of health and safety training.  

4.4.2 Appropriate health and safety training will be provided to support staff at all  levels to fulfil their health and safety responsibilities.   Records of this training  must be kept at department management level or on appropriate system  registers as implemented within NHS Fife.
4.4.3  New staff must complete the ‘welcome and orientation online training’ on their  first day of employment, this includes an overview of the mandatory training  modules, including Health and Safety. Thereafter there will be a requirement  to complete either mandatory e-learning module or face to face learning (role  dependent) within first three months of employment.

4.4.4 The Knowledge and Skills Framework (KSF) defines and describes the  knowledge and skills that staff need to apply to their work. Health and safety is  a core dimension within this framework.   This supports learning and  development of all staff with regards to health and safety and encourages the  application of the knowledge and skills they have developed.   Development of  health and safety knowledge by all staff is actively encouraged. 

4.4.5 Managers and staff should manage training needs in line with risk profiles and  risk assessments through the TURAS Appraisal system.

4.5  Specialist Advice

4.5.1 In order to assist Managers in fulfilling their responsibilities, specialist advice is  available from the NHS Fife Health and Safety Team.  

4.5.2 The department provides advice, practical assistance, training and support in  Health & Safety, Manual Handling and Violence & Aggression.

4.5.3 In addition, NHS Fife has the following sources of specialist expertise:

• Occupational Health Department
• Fire Safety Advisors
• Infection Prevention and Control Team
• Risk Management Team
• Radiation Protection Specialist external consultants


5.1 NHS Fife has a system in place to assess, record and where possible  eliminate risks and this must be followed.  A risk assessment must be  completed for risks that would stop NHS Fife from achieving its objectives and  this forms part of the Board assurance process.

5.2 High risks will form part of the Corporate Risk Register and BAF (board  assurance framework) which will be monitored, maintained and subject to  quarterly review.  

5.3 The NHS Fife Internal Audit Department will periodically verify the system of  internal controls and these findings will be presented via the Health and Safety  Sub-Committee and Board’s Audit & Risk Committee.


6.1 Appendix 1: Health & Safety Policy Statement
6.2 Appendix 2: NHS Fife and Fife Health and Social Care Partnership H&S Governance Structures
6.3 Appendix 3: Specific Arrangements for Radiation Safety


7.1   The Health & Safety at Work etc Act 1974
7.2   The Management of Health and Safety at Work Regulations 1999 (as amended)
7.3   The Health and Safety (Consultation with Employees) Regulations 1996
7.4   The Safety Representatives & Safety Committee Regulations 1977