Agenda item

Purpose of the item: To provide an update on the progress made implementing the actions from the Orbis internal audit report published in October 2023 on Health and Safety Governance Arrangements.

 

To provide an update on the improvements made to comply with the Health and Safety Executive (HSE) Improvement Notice dated 11 April 2023. In addition, the report includes a review of health and safety performance across schools and care homes. 

 

Witnesses:

Kevin Deanus, Cabinet Member for Fire and Rescue, and Resillience

Natalie Bramhall, Cabinet Member for Property, Waste and Infrastructure

Shella Smith, Director for People & Change

Glenn Woodhead, Assistant Director- Workplace & Facilities

Lesley Graham, Head of Health and Safety

 

Key points raised during the discussion:

 

Audit Response

 

1. The Chairman asked what involvement the Cabinet had in the Council’s Health and Safety Improvement Strategy. The Cabinet Member for Fire and Rescue, and Resilience explained that the leader of the Council had signed the Corporate Health and Safety And Wellbeing Policy, which was reviewed annually and there was good engagement with himself as the portfolio holder. There were quarterly reviews on health and safety performance and the Cabinet Member had a monthly review and portfolio reviews with the Leader of the Council, where performance and risks were discussed. An update on health and safety had gone to a meeting of the informal Cabinet in January 2024, which included progress on the actions from the internal audit. Once the Health and Safety and Wellbeing Strategy and Action Plan was developed, it would be shared with the formal Cabinet. Each portfolio lead within the Cabinet had a nominated individual as the health and safety lead.

 

The Cabinet Member for Property, Waste and Infrastructure joined the meeting at 10.06am

 

2. The Head of Health and Safety added that one of the actions from Internal Audit report was a member’s briefing, which resulted in the named health and safety leads being supplied to all the portfolio holders.

 

3. A Member asked how effective the Corporate Health and Safety Key Performance Indicators (KPIs) and its reporting system was. The Head of Health and Safety explained that new KPIs expanded on previous KPIs and provided a more detailed level of reporting and trend data, which easily identified areas for improvement. The KPIs were first recorded in the organisational effective report in March 2024 which showed a decline in the completion rates of accident incident reviews and the mandatory health and safety training. There was therefore a bigger focus from the health and safety leads within their directorates to ensure that report and improvement rates improved. The quarterly KPIs were taken to the Central Joint Health, Safety and Wellbeing Committee (CJHSWC), chaired by a member of the Corporate Leadership Team (CLT). Actions were taken back from service and health and safety leads to ensure directorates helped to support improvements. These KPIs are therefore more reflective than before but would continue to be reviewed over the next 12 months.

 

4. The Cabinet Member for Fire and Rescue, and Resilience explained that officers are measuring KPIs against the same quarters in previous years to gain an understanding of seasonal differences and trends.

 

5. A Member asked for an explanation of the role and importance of the Chair of the CJHSWC and if the chair’s rotation among CLT members effected the continuity of expertise and clear accountability. The Head of Health and Safety explained that the chair was responsible for overseeing the committee meetings. The Chair ensured this was reported to CLT, where minutes and slides were also shared to provide the key findings from the meeting. The CJHSWC is tasked with promoting and improving Health, Safety and Wellbeing across the council and complying with health and safety legislation. The chair of the CJHSWC was an important role, demonstrating the council’s commitment and legal responsibility to consult with its employees and representatives on health and safety matters. Having a member of CLT chair the meeting was reflective of the importance attributed to the health, safety and wellbeing of staff and the communities the council serves.

 

6. In relation to rotating the role of the Chair among CLT members, the Head of Health and Safety explained that it provided the opportunity for each member of CLT to be responsible for and involved in the promotion and improvement of health, safety, and wellbeing, and to understand their legal responsibility. It promoted a wider perspective of issues and areas for improvement across the whole council – rather than just in one directorate - and strengthened the message that health and safety is a collective responsibility. The CLT chair served for a whole year, which provided continuity and accountability for that year.

 

7. A Member asked if the health and safety training for senior management included executive leaders. The Member also asked why the health and safety refresher training would not be delivered until the new Chief Executive takes their post. The Head of Health and Safety confirmed that the training would be for Executive Directors and Directors but would confirm this outside of the meeting. The reason that the refresher training would begin after the new Chief Executive was in post was due to changes in the Corporate Leadership Team, with three new executive leaders being appointed. The mandatory health and safety training was refreshed every three years.

 

Action I: The Head of Health and Safety to check if the Health and Safety refresher training is for all executive leaders including Executive Directors.

 

8.    The Head of Health and Safety added that the audit report highlighted a completion date for the refresher training of sometime around 31May, and it had been agreed with Internal Audit that this date could be extended to 31 December. It was aimed to be completed before this.

 

9. The Vice-Chairman asked about the anticipated progress that the follow-up internal audit would report and what improvements were expected. The Head of Health and Safety explained it was anticipated that the follow-up audit would demonstrate Reasonable Assurance or Substantial Assurance, given that all but one of the internal audit’s actions had been completed. The Health and Safety Team were operating as expected to manage the key risks. Actions were agreed and were completed by the agreed timescales. Currently, the Strategic Lead for Health and Safety was the Deputy Chief Executive and the Executive Director of Resources. Therefore, a new Strategic Lead would need to be appointed for Health and Safety once the new Corporate Leadership Team structure had been agreed.

 

10. The Vice-Chairman asked about the planned timescales for Internal Audit’s review of Health and Safety. The Head of Health and Safety explained that internal audit had scheduled health and safety’s review for quarter two 2024/25, due to the target dates for implementing the two high risks actions. The first was reporting to the Resources and Performance Select Committee and the second was the Corporate Strategy and Action Plan which was going to a meeting of the Central Joint Health, Safety and Wellbeing committee on 16 May for approval. The actions were expected to be completed by the end of May. The Health and Safety review would hopefully start by the beginning of June.

 

Asbestos Management in Community Schools

11. The Vice-Chairman asked why the 23 schools that did not procure asbestos reinspection through the Council were not picked up and challenged sooner, and what methodology was employed in contacting schools to check what works had been undertaken. The Cabinet Member for Property, Waste and Infrastructure explained that all schools received revenue funding, which was used for the day-to-day running costs of the schools, such as head teacher remuneration, energy bills, teaching materials and maintenance tasks, and that schools can choose where they procure their property services. The Council offered property buyback schemes that were available to non-academy and academy schools. The schemes allowed schools to purchase various Planned Preventative Maintenance (PPM) compliance inspections with the appropriate remediation and reactive works. The buyback scheme was currently administered by the buyback co-ordinator employed by the Council. From 1 July 2024, this post would move to Macro, the Council’s facilities management supplier. There was an expectation that Macro would increase services offered to schools over the coming years, and potentially offer the service to other providers such as family centres. There was no process in place at the time of the Health and Safety Executive (HSE) visit, but a process had been developed following the inspection. A compliance questionnaire had been sent out to schools and site visits would be considered to audit schools’ responses to this. The schools not in the buyback scheme were contacted by phone to verify their arrangement and establish if they had asbestos containing materials (ACMs). The schools that had no ACMs and were not in the buyback scheme were visited by a school health and safety advisor to discuss arrangements, provide advice where gaps were identified, and action plan completion timescales were put in place where necessary. Where an urgent plan was issued, progress against the actions was followed up by advisors using a risk-based approach.

  

12. A Member suggested that better promotion of the buyback scheme and an explanation to schools of how it worked would be beneficial. The Cabinet Member for Property, Waste and Infrastructure agreed, noting that there is a process in place for the knowledge transfer, though the governing body had to hold Headteachers to account. Each school had their own access to an online system, and it was found that some schools had not logged onto the system when inspectors visited them.

 

13. The Assistant Director for Workplace and Facilities added that the scheme had been improved, making it more accountable in terms of the spend, the cost, and the services received through the buyback scheme. Therefore, it was more customer focussed and tailored to individual needs. There was now a drive to promote the buyback scheme, as it would ultimately be put through the Macro framework, which would provide incentives to grow the scheme compared to when it was a purely internal scheme. Within a few months, the buyback scheme should be an improved service.

 

14. The Chairman raised if it should be recommended to schools to have a governor responsibility for safeguarding. The Head of Health and Safety explained that all schools should appoint a Health and Safety Governor who should be part of the schools’ committees, and that the Council provided schools with a health and safety policy template. When a council Health and Safety Adviser performed an inspection of the school, they would ask the school governor, or the governor given the responsibility for health and safety, to attend the inspection to discuss this with them.

 

15. A Member asked if officers could provide more details on what was involved in the joint approach being undertaken by the Health and Safety Team, Land and Property Workforce, and Facilities Team to audit and monitor asbestos management plans where the Council was the employer. The Cabinet Member for Property, Waste and Infrastructure clarified that the school Health and Safety Advisers visited 25 schools between October 2023 and March 2024. A further 25 inspections were scheduled for April to July 2024 as agreed with the Health and Safety Executive. This did not include the 13 schools that were audited in June 2023. Using the Councils asbestos contractor, Tetra Tech, was being considered to provide additional capacity to increase the number of schools visited. Land and Property are liaising with Tetra Tech, who would become one of Macro’s subcontractors if pursued – the facilities management contractor responsible for managing all elements of building compliance for SCC, including asbestos management. The day-to-day responsibility for health and safety is delegated to the Headteacher and School Management Team, to ensure risks were effectively managed at the school. Monitoring visits were an opportunity to review performance with the school and where gaps had been identified the schools were provided with an action plan, which was then followed up on.

 

16. The Member asked if there were any schools where the council is the employer in which health and safety performance was of a concern to the Council. The Head of Health and Safety explained that they were not aware of any concerning schools with respect to health and safety performance. The monitoring visits would give the Council the opportunity to provide a targeted action plan.

 

17. The Member asked whether the HSE is satisfied with the Council’s timeframe for monitoring the schools. The Head of Health and Safety explained that a discussion with the HSE took place in March 2024, and the principal inspector present at the meeting recognised that it was a significant undertaking, with around 100 schools where the council is the employer. It was agreed with the HSE that an additional 25 visits would be undertaken in addition to those already completed. The two-year monitoring programme had been benchmarked against the performance of other neighbouring authorities. The HSE agreed that this was adequate for 2024.

 

18. A Member raised a concern around burdening schools with asbestos management when schools already work in a challenging environment, especially given rising costs. The Assistant Director for Workplace and Facilities explained that this was covered in the Asbestos Management Plans developed for each of the different sites and schools. It was ensured that the Council’s legal responsibilities were covered and, within the plans, it would be identified where the asbestos was and whether it could be contained or removed. The Assistant Director highlighted that schools, with the number of pupils moving around the building, were at a higher risk of having asbestos that was not contained being disturbed. When asbestos reviews were completed, school sites are assessed to ascertain whether the asbestos-containing areas could be adequately contained. It was noted that Facilities Management use a system called Teams to record information about the specifics of each different school site and their asbestos-containing materials.

 

19. A Member asked what sanctions could be placed on schools if issues relating to asbestos raised by the council, or advisers, were not addressed. The Assistant Director for Workplace and Facilities stated that they would confirm this and respond to members after the meeting. The council seek to ensure that those situations were managed correctly, which so far was done very well. The HSE had managed to identify some weaknesses within the current process, which work had been done to improve. Within schools where the council had control, it was easier to ensure asbestos was managed correctly, compared to schools where the council were not the employer or had lesser control under the particulars of the lease agreement.

 

Action II: The Assistant Director for Workplace & Facilities to check if there are any sanctions for schools that do not comply with requested asbestos works.

 

20. The Cabinet Member for Property, Waste and Infrastructure added that there was a high compliance rate of 96%, meaning that such sanction regimes are seldom necessary. With the Facilities Management service being outsourced to Macro, this would hopefully improve further.

 

Children’s Homes

 

21. The Vice-Chairman asked if there were any children’s homes where the council was the employer in which health and safety performance was of concern. The Head of Health and Safety explained that aside from the children’s homes opened so far in 2024, all the homes had had health and safety inspections. Where gaps were identified, the Home Manager was provided with an action plan and dates for the implementation of actions. These actions would be followed up with an adviser within the agreed timeframes. The Children, Families and Lifelong Learning (CFLL) directorate’s Health and Safety Advisers had a good relationship with the Home Managers. One of the children’s home managers sat on the CFLL Health and Safety Committee, representing the other Home Managers and ensuring effective two-way communication regarding risks and issues, feeding these back to other managers. The significant findings from the inspections demonstrated that the children’s homes had systems in place to manage health and safety arrangements.  There were nevertheless some gaps such as with some of the building compliance records, with statutory certificates not available during the inspection, gaps in knowledge around the children’s homes health and safety roles and responsibilities, risk assessments overdue for reviews and on-site traffic management.

 

22. The Chairman asked if some context could be given around the 119-workplace health and safety incidents involving employees and service users recorded on OSHENS (a tool for reporting and reviewing health and safety incidents and injuries) in the past year. The Chairman also asked what kind of incidents would be placed in each category, and if the number was what was expected. The Head of Health and Safety explained that the health and safety advisers had been promoting the reporting of incidents on OSHENS with staff in their directorate for the past year. This resulted in an increase in numbers being reported, which was seen as a positive change in reporting, creating an improved health and safety culture and engagement with staff. It provided opportunities to share learning and discuss what more the Council could do to support staff and service users.

 

23. The Head of Health and Safety provided an overview of the reported incidents categories. There were 14 incidents placed in the ‘Abuse, threat and violence’ category, comprising verbal abuse, threatening behaviour, assault, and behavioural issues. Most of those incidents related to managing challenging behaviour in young people where staff were unable to put in suitable de-escalation techniques. Once incidents were reported, they would follow-up actions and staff training where gaps were identified, with support from managers. There were 18 ‘near-miss’ incidents, which fell into the categories of ‘Self-harm’, ‘Medication errors’, ‘Illness’, ‘Unplanned medical interventions’, ‘Harmful substance or exposure to harmful substance’, ‘Burns through hot liquids or surfaces’, ‘Contact where children were hit by a fixed object’ ‘Contact where children were hit by a moving vehicle’, and ‘A fall from height’. The increase in near-miss reporting provided insightful data and demonstrated understanding of the service to record incidents. It was recognised one or two should have been reported as an injury rather than a near-miss. There were 87 incidents of injury, including injuries to staff, children, and young people. These were within areas of ‘Self-harm’, ‘Violence’, ‘Slips, trips, and falls’, ‘Behavioural issues’, ‘Cuts’, ‘Injuries involving electricity’, ‘Burns’ and ‘Contacts’. Incidents of abuse and violence against staff or other residents often lead to injury, some of which could be minor. The more serious incidents were around self-harm and violence/assault on a person.

 

24. The Chairman asked if there was an indication of how the categorisation of incidents compared to that of other local authorities. The Head of Health and Safety explained that other authorities had a different make-up and may have had a different number of homes, children, and age ranges. There had been an increase in the number of reports, due to the awareness and improved reporting. The Health and Safety Team worked hard with service leads and representatives to ensure staff were encouraged to report. It would therefore be difficult to compare to other local authorities with the different variables involved.

 

25. The Head of Health and Safety noted the nature of the incidents, particularly around incidents of abuse, threats, violence, and self-harm, were not likely to reduce due to factors such as the experiences of children and young people in homes.

 

Resolved:

The Resources and Performance Select Committee recommends that:

1. In order that Cabinet takes accountability for the Council’s Health and Safety Improvement Strategy (as recommended by the Local Government Association), Cabinet (in addition to the Central Joint Health, Safety and Wellbeing Committee) endorses the Health, Safety and Wellbeing Strategy and Action Plan 2024-2026;

 

2. In order to promote awareness of the key risks across all directorates, all Executive Directors are informed and updated on the Central Joint Health, Safety and Wellbeing Committee by its rotating chair;

 

3. The new suite of Corporate Health and Safety Key Performance Indicators agreed with the Corporate Leadership Team on 19 September 2023 are presented to Cabinet Members quarterly and included in the quarterly Resources and Performance Select Committee performance monitoring reports;

 

4. Ahead of May 2025, the Members’ Induction booklet must refer to Health and Safety (H&S), clarifying how and to whom members should refer any H&S issue that comes to their attention.