If you have previously completed version 5 of this risk assessment it should not be necessary to complete the risk assessment again using this document unless there have been any significant changes in your health to affect your risk group.

You may also have completed the Return to Work Risk Assessment for Red Risk and Shielding Staff. If so, you do not need to complete this document in addition.

Please ensure you keep up to date with all Trust communications and revisions of this document.

1

Individual Staff Risk Assessment Pack for Covid-19 (WSH) – Version 6,October 2020For all staff including Black, Asian and Minority Ethnic (BAME), pregnant and other at-risk staff groups

West Suffolk Hospitals NHS Foundation TrustOH Occupational Health and Wellbeing and Covid-19 IMT

Version number:

6

Version date: 23 October 2020

All staff are reminded to follow all guidance – additional information is available on the staff portal at https://www.wsh.nhs.uk/covid-staff-zone/HR-help/Staff-risk-assessment-checklist.aspx

This pack includes:

Section A

Employee completes

Covid 19 – Individual Self-assessment checklist including risk stratification for asthma

Section A should be provided to all employees to review and then confirm with their manager their risk group. This does not need to be repeated if version 5 of the risk assessment has already been completed unless the individual has any significant changes in their health which may affect their risk group

Section B

Employee & their line manager to review and complete supplementary risk assessment as appropriate

Covid 19 – Risk assessment and work placement (previous appendix 3 in Risk Assessment version 5 with updated guidance on red risk group)

Section C

Employee & manager complete where appropriate (Orange/Yellow Risk Group)

Supplementary Risk Assessment for Individuals in Orange/Yellow risk groups including Checklist

Section D

Employee & manager complete where appropriate (Red Risk Group)

Supplementary Risk Assessment for Red risk group including those shielding work questionnaire, checklist and option for occupational health referral if further guidance is required

Appendices Supporting information and referral forms

Appendix 1: Occupational Health Management referral – work advice for red shielding risk group staff

Appendix 2: Occupational Health pre-

2

consultation questionnaire – work advice for red shielding risk group staff

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SECTION ACovid 19 - Individual Self-assessment checklist For all staff including Black, Asian and Minority Ethnic (BAME), pregnant and other at-risk staff groups

All employees to complete (if not previously completed version 5)

Section A

Covid 19 - Individual Self-assessment checklist

Please review and complete the following document and update your line manager as to the outcome of your risk assessment individual risk group.

Should you require further advice or guidance once completed please contact Occupational Health and Wellbeing on 01284 713424.

Please ensure you keep up to date with all Trust communications and revisions of this document.

All staff are reminded to follow the following guidance – additional information is available on the staff portal at https://www.wsh.nhs.uk/covid-staff-zone/Home.aspx

Comply with social distancing guidance in all areas, including during breaks and in public areas.

Limit duration of close interaction with patients as much as possible (e.g. prepare everything in advance away from patient). When possible maintain >2m distance from the patient.

Ensure infection control training is in date.

Ensure you are familiar with all personal protective equipment (PPE) scenario levels relevant to your role and work area. The Trust has PPE scenario levels available at the following https://www.wsh.nhs.uk/covid-staff-zone/Uniform-equipment-and-PPE/Uniform-Equipment-and-PPE.aspx

Ensure you are aware of how to use PPE, including knowledge of availability, fit, correct donning and doffing, and what actions to take if PPE is not available.

No work should be undertaken in any area unless adequate PPE is available.

Escalate any concerns about PPE availability.

Ensure that you are aware of the actions to take if you develop any Covid-19 symptoms.

Ensure you are aware how to arrange rapid access testing service for symptomatic staff and household members.

Covid-19 related absence (e.g. self- isolation for symptoms, isolation as a household member, isolation in relation to shielding) is supported by the Trust and will not impact negatively on pay or career progression.

Psychological support is available for any staff member concerned about their vulnerability to Covid-19.

4

Consider whether public transport /rush hour can be avoided through adjustments to work hours or accessing alternative travel arrangements.

5

Name of Staff Member

Job Title

Department/WardINDIVIDUAL HEALTH ASSESSMENT

Tick answerRisk group details

Yes NoAre you in the very high risk category?

i.e. red risk category

VERY HIGH RISK (red)Clinically extremely vulnerable (shielding group) including the following: Solid organ transplant recipients People with specific cancers:

o People with cancer and are having chemotherapy o People with lung cancer and are having radical radiotherapy o People with cancers of the blood or bone marrow such as leukaemia,

lymphoma or myeloma who are at any stage of treatment o People having immunotherapy or other continuing antibody treatments for

cancer o People having other targeted cancer treatments which can affect the

immune system, such as protein kinase inhibitors or PARP inhibitors o People who have had bone marrow or stem cell transplants in the last 6

months, or who are still taking immunosuppression drugs People with severe respiratory conditions including all cystic fibrosis, severe

asthma and severe COPD. People with rare diseases and inborn errors of metabolism that significantly

increase the risk of infections (such as SCID, homozygous sickle cell). People on immunosuppression therapies sufficient to significantly increase risk of

infection. If in doubt please contact Occupational Health (OH)for advice Women with significant heart disease, congenital or acquired who are pregnant (at

any stage of pregnancy) other people who have also been classed as clinically extremely vulnerable, based

on clinical judgement and an assessment of their needs. GPs and hospital clinicians have been provided with guidance to support these decisions

The following have also been identified by specialist groups as high risk and requiring shielding: People with severe diseases of body systems, such as severe kidney disease

(dialysis), frequently relapsing nephrotic syndrome of those with a current nephrotic range proteinuria, etc.

People with a neurological condition that has been identified as high risk as detailed in the guidance from the Association of British Neurologists Guidance on COVID-19 for people with neurological conditions, their doctors and carers available at the following link - https://cdn.ymaws.com/www.theabn.org/resource/collection/65C334C7-30FA-45DB-93AA-74B3A3A20293/ABN_Neurology_COVID-19_Guidance_v6_9.4.20_FP.pdf

Other groups not in the shielding group but considered clinically vulnerable and to be treated as very high risk: Those who are pregnant (after 28 weeks pregnant) Asthmatics who are on high dose inhaled steroids and have any of the identified

risk factors detailed in the Stratification for staff with asthma algorithm. The majority of staff in the red group will be in the Public Health England “shielding group” and will have been contacted individually by the NHS. If you are concerned that you should be in the red group but have not received a shielding letter or text, please contact Occupational Health.Staff in the red group should work from home where possible and only attend the workplace when the recommendation to shield has been lifted. There is a return to work guidance for this group and they must complete – section D.

For staff who are pregnant and in the third trimester (greater than 28 weeks) or have an underlying health condition, such as a heart or lung disease, the individual’s pregnancy risk assessment should also be taking into account the current RCOG guidance Occupational health advice for employers and pregnant women during the COVID-19 pandemic

6

INDIVIDUAL HEALTH ASSESSMENT

Tick answerRisk group details

Yes NoAre you in the heightened risk category?

i.e. orange risk category

HEIGHTENED RISK (orange)o Aged 65* or older o Aged 60* or older and EITHER male OR from a BAME background o Aged 55* or older AND are male AND from a BAME background o Under 65 with an underlying health condition listed below (ie anyone advised to have a flu

jab each year on medical grounds):o Chronic (long-term) respiratory diseases, such as asthma (see Stratification for Staff

with Asthma algorithm), chronic obstructive pulmonary disease (COPD), emphysema or chronic bronchitis. Latent tuberculosis is not considered high risk (i.e. Green). Past TB where there may be post TB lung damage may make individuals more vulnerable to chest infection so is deemed increased risk – i.e. yellow increased risk (i.e.yellow) (contact occupational health if you are unsure)

o Chronic heart disease, such as heart failure Asymptomatic heart valve disease is not considered high risk (i.e. Green). Individuals with complex congenital heart disease are considered at heightened risk, as are those with symptomatic heart valve disease and pregnant staff with cardiac conditions

o Chronic kidney diseaseo Chronic liver disease, such as hepatitis – NB Asymptomatic hepatitis B & C with no co-

morbidities is not considered high risk (contact occupational health if you are unsure whether you should be in the orange or green group)

o Chronic neurological conditions, such as Parkinson’s disease, motor neurone disease, multiple sclerosis (MS), a learning disability or cerebral palsy

o Diabetes o A weakened immune system as the result of medical conditions or medication NB well

controlled HIV with CD4 count ≥ 200 or above and undetectable viral load, on ART is not considered heightened risk (i.e. Green). Contact occupational health if you have a weakened immune system due to medical condition or medication if you are unsure whether you should be in the green, orange or red group.

o Problems with your spleen – for example, sickle cell disease or if you have had your spleen removed – please contact occupational health

o Being seriously overweight (a body mass index (BMI) of 40 or above)o Those who are pregnant (before 28 weeks) – we advise this risk assessment is undertaken

with the New and Expectant Mothers risk assessment checklist, with an aim that the risk of exposure to Covid 19 in the work setting is no greater than the risk of exposure out of the work setting. Please refer to the current RCOG guidance Occupational health advice for employers and pregnant women during the COVID-19 pandemic when completing the pregnancy risk assessment

o Those with poorly controlled hypertension, secondary hypertension or hypertension with an associated cardiac condition. Well controlled hypertension with no cardiac complications/ effects (eg left ventricular hypertrophy) including those treated with ACE (angiotensin-converting enzyme) inhibitors or ARBs (angiotensin-receptor blockers) are not considered heightened risk. (i.e. Green)

There is a wide spectrum of risk in the Orange group from members of staff whose vulnerability to coronavirus is unlikely to be significantly higher than colleagues with no risk factors, to those whose vulnerability is approaching that of colleagues in the red group. Age, gender, ethnicity and obesity are important factors that need to be taken into consideration when considering individual risk.

For this reason there has been some risk stratification of certain common conditions as detailed above and in the Stratification for Staff with Asthma algorithm with the following outcomes STANDARD RISK – revert to green risk category INCREASED RISK – yellow HIGHER RISK - orange Occupational Health can advise when it is unclear which group a member of staff is in but does not need to be contacted if the member of staff and their manager have sufficient information on which to base a risk assessment.

Please seek specific advice from Occupational Health for the following: Age as a risk factor*If the staff member is 5 years over the age threshold for any of these categories. e.g. 70 years old with no medical conditions / Male, BAME and 60 More than two risk factors Individuals who have two or more risk factors in this group may have a higher level of vulnerability to COVID-19.If you are concerned that these may apply please contact occupational health to discuss whether a higher level of precaution is needed.

7

INDIVIDUAL HEALTH ASSESSMENT

Tick answerRisk group details

Yes NoDoes the staff member fall into neither the orange or red category above

i.e. Green risk category

Green Risk group

If not highlighted by any of the criteria set out in either red or orange risk group then individuals are classified as - STANDARD RISK - green - social distancing group.

Workplace adjustments may need to be considered because of pre-existing health problems or disability, unrelated to a vulnerability to Covid-19 e.g. pre-existing anxiety aggravated by Covid-19 outbreak, a health condition that makes it difficult to work using PPE. Reasonable adjustments may be required.

For all staff in the standard risk green group, line managers should ensure staff are aware of the guidance on page 4, assess how best to implement it (with adjustments if required) and identify who they should inform of any associated difficulties or concerns.

Self-Assessment Outcome

Risk assessment outcome and work placement

Red Orange+ Yellow+ Green+ for orange and yellow risk group an individual risk assessment is required to determine appropriate activities

OH advice sought Yes/No

Signature of Staff Member

Date of Assessment

Name of Assessor/manager

Risk assessment outcome and work placement

Red# Orange+ Yellow+ Green+ for orange and yellow risk group an individual risk assessment is required to determine appropriate activities and an supplementary staff risk assessment may need to be completed with their manager (Section C)

# for red risk group a supplementary staff risk assessment for red risk group staff should be completed with their manager (Section D).

OH advice sought Yes/No

Date of Assessment

Signature of Assessor/manager

Please note:

By signing above you are confirming that the Risk Assessment has been discussed with the member of staff and identified action taken.

8

Stratification for Staff with Asthma

9

OCS / yr means the number of courses of high dose oral prednisolone (e.g. ≥ 0.5 mg / kg) for at least 3 days within the past one year.ICS means inhaled steroid. INH means inhaler.Additional controller refers to taking certain extra medicines as well as a preventer inhaler (for example, montelukast, salmeterol or formoterol, or you are on a combination inhaler such as Seretide, Fostair, Symbicort, Flutiform, Fobumix, DuoResp Spiromax, Combisal, Sereflo, Sirdupla, Aloflute, AirFluSal, Relvar, Ellipta, Fusacomb or Stalpex.

RED and gov’t criteria for shielding

Asthmatics in the shielded group should

have received correspondence from

their GP

No

Rescue inh < 3x /wkAND

OCS < 2 /year

NoYes

GREEN

YELLOWRecommend GP treatment review

On inhaled steroid

Yes: Consult BTS table to check if low / medium or high dose

Rescue inh < 3x /wkAND

OCS < 2 /year

LOW DOSE ICS MEDIUM DOSE ICS +/- extra controller

HIGH DOSE ICS + extra controller

Yes No

GREEN

RED – please contact OH to

confirm risk group

Presence of ≥ 1 additional risk factor:

- Hospital admission in last year- Intensive care treatment ever- Steroid orally daily (prednisolone)- Antibiotic orally weekly (azithromycin)- ≥ 4 oral steroids / yr- Smoker or vaper

HIGH DOSE ICS with extra controller AND one of the following:

On maintenance prednisolone or frequent oral steroids

On a biologic therapy: Mepolizumab (Nucala) Benralizumab (Fasenra)Reslizumab (Cinquero)Omalizumab (Xolair)

Rescue inh < 3x /wkAND

OCS < 2 /year

Yes No

YELLOW ORANGE

No Yes

YELLOWRecommend GP treatment review

Consider elevating one colour risk level if smoker / vaper or age > 50 – Please contact OH to confirm risk group

Asthma Inhaler Strength Classification:https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/

10

11

SECTION BStaff Risk Assessment

Work activities & management actions

Employee & their line manager to review complete supplementary risk assessment as appropriate

Section B: Individual Staff Risk Assessment Checklist for Covid-19 – Version 6 – Work activities & management actions

Please complete risk assessment and discuss with your line manager control measures, taking into account advice below on local risk assessment:Red – very high risk groupStaff in this group should work from home when a shielding requirement is in operation (nationally or locally) and, when one is not, should undertake stringent social distancing and avoid work areas where there is high risk of Covid-19 exposure

Orange - heightened risk group Advise stringent social distancing. Undertake local risk assessment before work in areas where high risk of Covid-19 exposure.

Yellow - increased risk group Advise stringent social distancing. Undertake local risk assessment before work in areas where high risk of Covid-19 exposure.

Green – standard risk group No heightened risks identifiedStandard risk group Social distancing

Work activities

Those staff with shielding letters should comply with the shielding recommendation and only work from home during period when shielding is recommended. Individuals allocated to the red risk group should also work from home whilst shielding is recommended. There may be exceptional circumstances where staff in the red group may be able to undertake some work on site but this should only been with the agreement of the individual, their manager and following consultation with occupational health

As shielding is lifted staff in this group may return to work to Covid-Secure environments and green / certain amber areas but must complete a Staff Risk assessment for red risk group staff. This document should include the agreed measures in place to reduce risk of exposure. If work in amber area or other area please seek advice from Occupational Health by completing the referral form as detailed in section D.

Staff who are pregnant and in the red risk group due to gestation or additional health condition should have regular review of their New and Expectant Mothers Risk Assessment, taking into account Covid-19 in addition to other workplace hazards. This should take into account the current RCOG guidance, which can be accessed at https://www.rcog.org.uk/globalassets/documents/guidelines/2020-09-10-occupational-health-statement-rcog-rcm-fom.pdf

Ensure that staff are aware that psychological support is available for any staff member concerned about their vulnerability to Covid-19

Work activities

May work in areas other than green / amber areas but must complete a local risk assessment and agree measure in place to reduce risk of exposure with their line manager

Must not work in an environment where there is the potential for unprotected and uncontrolled exposures to possible/confirmed Covid positive patients, particularly in areas where aerosol generating procedure (AGP) are undertaken i.e. PPE category red.

Staff should not undertake tasks if they believe there are significant risks.

Work activities

May work in areas other than green / amber areas but must complete a local risk assessment and agree measures in place to reduce risk of exposure with their line manager

The Trust PPE scenario levels available at the following https://www.wsh.nhs.uk/covid-staff-zone/Uniform-equipment-and-PPE/Uniform-Equipment-and-PPE.aspx.

Work activities

Able to work in all areas

The Trust PPE scenario levels available at the following https://www.wsh.nhs.uk/covid-staff-zone/Uniform-equipment-and-PPE/Uniform-Equipment-and-PPE.aspx.

Management actions:Facilitate work from home where possible and complete the Staff Risk assessment for red risk group staff process for those staff who cannot work from home

Management actions:Complete Individual checklist for Individual Local Risk Assessment for Orange/Yellow Risk Groups

Management actions:Checklist for Individual Local Risk Assessment for Orange/Yellow Risk Groups

Management actions:Discuss any concerns highlighted by staff member

For all staff working reiterate standard infection control advice and personal protective measures. Ensure aware of increased precautions and recommendations implemented because of coronavirus. https://www.wsh.nhs.uk/covid-staff-zone/Uniform-equipment-and-PPE/Uniform-Equipment-and-PPE.aspx.

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13

SECTION CSupplementary Staff Risk Assessment

Only employees in Orange/Yellow risk group to complete with their manager

Please ensure you follow Trust wide communication and guidance, especially if there is a local or national change such that increased precautions for vulnerable staff are required.

Supplementary Risk Assessment for Individuals in Orange/Yellow Risk Groups including Checklist

Name of Staff Member

Job Title

Department/Ward

Name of Assessor

Date of Assessment

Signature of Assessor

Signature of Staff Member

14

It is acknowledged that some staff with well managed underlying health conditions or other risk factors may wish to continue to work without restrictions to their practice. This can be supported if a supplementary risk assessment has been completed to ensure the risk of exposure is reduced to as low as is reasonably practicable and that the individual is comfortable with the level of risk.

It should be a personal decision for the healthcare worker as to whether they wish to work in Covid-19 areas.

Green / amber areas are considered non-Covid. Amber areas are where patient status is uncertain and unlikely and follows the Medium Risk Covid Pathway. Red area is where patients have a clinical diagnosis of Covid-19. Where the healthcare worker wants to continue working in amber or red areas it is important that a local risk assessment is carried out to determine how risks can be best managed. It is important that the staff member is content with the outcome of the risk assessment and is comfortable with the level of personal risk.

Advice is available to staff and their managers if there are any questions or concerns about this. Depending on the nature of this an enquiry could be directed to more senior management, Employee Relations/Medical Staffing, Occupational Health or Health and Safety.

If staff wish to continue to work in amber and red areas following actions are required:

Document measures to reduce exposures as far as reasonably practicable and any specific modifications required.

Confirm that the HCW and their line manager are comfortable with the control measures that are in place and know they can request to review the decision at any time.

Review checklist to ensure all possible controls are considered and included if appropriate.

Details of agreed workplace adjustments/adjusted duties:

o

o

o

o

o

o

o

For all staff with an individual risk assessment a Covid-19 Risk Assessment Checklist must be completed with agreed actions – see overleaf

Tick those that apply

AGREED ACTION PLAN: (Please tick those that have been discussed/agreed)

Stringent social distancing – limit duration of close interaction with patient as much as possible (e.g. prepare everything in advance away from patient), when possible maintain >2m distance from the patient Consider asking patients to wear a mask for staff member interactions

Ensure infection control training in date

Review PPE use to ensure availability, fit, correct donning and doffing and staff knowledge of the actions to take if PPE is not available

15

Ensure staff are aware how to escalate any concerns about PPE availability

Ensure that staff are aware of the actions to take if they feel unwell with Covid-19 symptoms

Ensure that staff know about access testing for symptomatic staff and household members.

All staff should be reassured that Covid-19 related absence (e.g. self- isolation for symptoms, isolation as a household member, isolation in relation to shielding) is supported by the Trust and will not impact negatively on their pay or career progression. Ensure that staff are aware that psychological support is available for any staff member concerned about their vulnerability to Covid-19. Consider whether public transport /rush hour can be avoided through adjustments to work hours

Review if any workplace adjustment are required due to an underlying health condition/disability, these should be discussed with management and a plan agreedIf work restrictions are not considered to be operationally practical or an individual risk assessment is not appropriate in the current role - consider temporary redeployment to an alternative work area within the Directorate or wider Trust, where exposure risk is lower.

Escalate decisions within your departmental or divisional structures, if needed. If there are any concerns raised by the staff member or manager about the outcome of the risk assessment process please seek further support from HR.

OH advice sought & outcome?

Further actions to be taken to reduce risks(further actions needed only for “yes” answers)

By whom By when Date completed

The completed checklist

should be filed in the staff members Personnel file.

Review this risk assessment on a regular basis and close when no longer applicable.

16

SECTION DSupplementary Staff Risk Assessment

Only employees in the Red risk group (including those previously shielding) to complete with their manager.

Supplementary Risk assessment Questionnaire – Red risk group (including those previously shielding)

The following questionnaire should be completed by the employee to facilitate a discussion with their line manager to help facilitate safe work in the workplace or ongoing work from home during the pause to the shielding recommendation

Sections 1 and 2 should be completed by the staff member prior to a discussion with the managerSections 3 and 4 by the line manager along with input from the staff member

Name of Staff MemberJob TitleDepartment/WardSection 1 Confirmation of risk group/status – Staff member to complete

Shielding status Yes No1.1 Did you receive a shielding letter?1.2 Have you had contact with Occupational Health (OH) and been advised that

you are in the red risk group1.3 Has anything changed in your health to make you believe your status may

have changed since the initial assessment e.g. change in treatment, etc.Details

Section 2: Work details and travel to work – Staff member to completeWork activities Yes No

2.1 Are you currently well enough to work i.e. not on current sickness absence? If no, your manager should consider management referral to OH as part of sickness management process.

2.2 Is there a need to return to the work environment to undertake your work activities?

Details of job role, any difficulties working from home and measures which were previously in place to facilitate working whilst shielding

Please detail any support measures/reasonable adjustments that would help you to work effectively from home or enable you to safely return to the workplace

Do you have any specific questions or concerns about your health and work?

17

Travel to work Yes No2.3 Are you able to travel to work without using public transport? i.e. walking or

cycling (including walking and cycling from the park and ride) or you already have staff parking rights supporting your work pattern)?If the answer is ‘no’ please discuss with your line manager whether temporary access to parking on site would be appropriate.

2.4 Are there travel difficulties for which alternative options need to be considered? E.g. Access to Work/taxis/accommodation If ‘yes’ to this question please discuss with your manager referral to occupational health – see appendix 1

Section 3 : Work environment & Welfare – Manager to completeWork Environment

Please answer these questions to help inform the discussion as to return to work Yes No

3.1 Has a Covid-secure risk assessment been undertaken for the work environment? https://www.wsh.nhs.uk/covid-staff-zone/Templates/Health-and-Safety/COVID-19-workplace-inspection-template.docx

3.2 If the work area where the staff member is due to work is not Covid secure please refer to OH with appendix 1Please include any details of local risk assessments to aid the OH assessment.

3.3 If the staff member is pregnant has the New and Expectant Mother’s Risk assessment check list been reviewed and discussion held regarding when the individual wished to start their maternity leave N/A

Please give details

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Section 4: Individual Risk assessment checklist – to be completed by manager with staff member prior to work in the workplaceName of Staff MemberJob TitleDepartment/WardName of AssessorDate of Assessment

Covid Secure Workplace - Individual risk assessment – red risk group

It is acknowledged that some staff in the VERY HIGH RISK (red) clinically extremely vulnerable (shielding group) will need additional precautions and also may need to shield again in the future depending on the level of circulating Covid-19.

It should be a considered decision for the staff member in conjunction with their line manager as to whether they work in clinical areas and whether there need to be and restrictions to the work activities. This may require referral to occupational health for further assessment and guidance.

Red risk group staff should normally only work in green (non-Covid-19) areas. There may be some amber areas where staff can work. If an individual wishes to work in areas other than green (non-Covid-19 area) a referral to OH should be completed so further assessment can be undertaken.

Employers have a duty to reduce risks to as low as reasonably practicable and should not expect shielded staff to work in areas where there is a greater risk in the workplace than elsewhere. PPE can provide mitigation of risk. If it is not thought that this level of risk control is possible in the current role, occupational health referral should be organised for further detailed assessment and advice.

It is important that the staff member is content with the outcome of the agreed workplace adjustments and is comfortable with the level of personal risk.

Advice is available to staff and their managers if there are any questions or concerns about this. Depending on the nature of this, an enquiry could be directed to more senior management, Employee Relations/Medical Staffing, Occupational Health or Health and Safety teams.

Please detail in this checklist: Measures to reduce exposures, as far as reasonably practicable, and any specific

modifications required. Whether the staff member and their line manager are comfortable with the control measures

that are in place and know they can request to review the decision at any time. Review of the checklist to ensure all possible controls are considered and included if

appropriate.

Details of agreed workplace adjustments/adjusted duties:For example: staggered start time, avoidance of certain activities e.g. running errands, avoid hot desking, etc.

o

o o

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Control measures checklist and agreed specific individual actions/measures Tick those that apply

Work in green/non-Covid areas only

Stringent social distancing – minimise close interaction with people and, when possible, maintain >2m distance Use of appropriate PPE where >2m distance cannot be maintained

Ask patients to wear a mask (where possible) for staff member interactions Ensure infection control training in dateReview PPE use to ensure availability, fit, correct donning and doffing, and staff knowledge of the actions to take if PPE is not availableEnsure staff are aware how to escalate any concerns about PPE availabilityEnsure that staff are aware of the actions to take if they feel unwell with Covid-19 symptomsEnsure that staff know about access testing for symptomatic staff and household members. All staff should be reassured that Covid-19 related absence (e.g. self- isolation for symptoms, isolation as a household member) is supported by the Trust and will not impact negatively on their pay or career progression. Ensure that staff are aware that psychological support is available for any staff member concerned about their vulnerability to Covid-19. Discuss how to avoid public transport /rush hour travel through adjustments to work hours and an application for access to parking on site if required – tick to confirm. Review if any workplace adjustment are required because of an underlying health condition/disability, these should be discussed with management and a plan agreedIf work restrictions are not considered to be operationally practical or an individual risk assessment is not appropriate in the current role – Refer to Occupational Health OH advice sought & outcome?Further actions to be taken to reduce risks(further actions needed only for “yes” answers)

By whom By when Date completed

The completed checklist should be filed in the staff members Personnel file. Review this risk assessment on a regular basis and close when no longer applicable.

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Appendix 1

Occupational Health Management Referral - work advice for red risk/shielding risk group staffAll information will be treated in the strictest confidence. Following a consultation with OH (Occupational Health and Wellbeing), the employee will be asked to consent to a report based on the consultation and the information you have provided. Following a telephone assessment an OH report will be issued providing advice on five standard questions. If a more comprehensive management referral is required due to long term sickness absence or other reasons, please use the standard OH management referral.

Section 1: Employee DetailsFirst Name Surname

DOB Job TitleDepartment & Box Number

Work Extension Number

Are there any times or days to avoid?

Please supply at least one of the following:Home Number Mobile Number

Can a message be left on:

Home Phone: Yes Mobile Phone: Yes

Please tick this box if a message cannot be left

Home Address (required for appointment letter)

Work Email Address

Section 2: Referrer DetailsFull Name

Job Title

Department & Box Number

Division/Corporate Area

Extension Number

Email Address

HR Contact

HR Email Address

The employee has been informed of this referral and all details given in this form were discussed with the employee on:

If completing this form electronically enter your name and dates in the fields below and then check the following box to indicate that you confirm the information given in this form 

Date Signature

Section 3: About the RoleLength of time in current role

Total number of years worked at the Trust

Work PatternThe individual’s normal hours of work are: Shift work Night worker Rotating shifts Normal office hrsContracted Hours: (00:00) - (00:00)

Please indicate the hazards that affect this roleSpecific hazards/ task Working with biological agents, human tissue and/or blood

Contact with patients in a clinical environment

21

Undertaking Exposure Prone Procedures (EPPs) Undertaking aerosol generation procedures (AGPs) On call /out of hours work Driving for work Food handling/preparation DSE user Manual handling Work with respiratory sensitisers/ Irritants (including latex) Work with to skin sensitisers /irritants Other (please specify)_____________________________ No Hazards Apply

About this ReferralShielded /extremely clinically vulnerable staff member – Covid-19 return to work advicePlease provide any relevant details as to the reasons for referral. Please include any details of workplace risk assessments completed to help inform the discussion

Questions that will be addressed by the OH assessment:1. Please confirm which risk group the staff member falls? E.g. red (shielding), red, etc.2. Please confirm if their risk group status is likely to be temporary or permanent?3. What adjustments and/or restrictions may be proportionate in view of vulnerability to severe

Covid-194. Are these adjustments/restrictions are short term or will be required until the Covid-19

outbreak is controlled5. Would it be appropriate to consider temporary or permanent redeployment?Is there any further information that may be helpful in supporting the employee’s health at work?

If appropriate, what home working, reduced hours and/or restricted duties could your service support?

Once completed please email to occupational.health@wsh.nhs.uk from your West Suffolk email account. Please do send any supporting documentation that may be helpful for example your

department’s Covid Secure risk assessment.

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Appendix 2

Occupational Health Pre-Consultation questionnaire – red risk/shielding risk group staff

Please return this ahead of your consultation to help OH triage your referral to the most suitable clinician. Once both the management referral and this questionnaire have been received by occupational health a telephone appointment will be scheduled. Please do not return this to your manager but send back directly to Occupational Health - Email to occupational.health@wsh.nhs.uk.

Section 1: Employer/Job DetailsEmployer NameJob titleDepartmentHow many hours per week?Manager’s nameSection 2: Personal DetailsSurname First name (s)

Title e.g. Dr, Mr, Mrs, Miss, Ms

I identify my gender as:

Maiden name / previous surname (s)

Date of birth

Your home address:

Postcode:Email address:In case we need to contact you, please give one or more phone numbers where we may contact you during the day:

Is this your home, mobile, or work number?

May we leave a message stating who we are?

No Yes

If you have provided a mobile number, please tick the box to the right if you are happy for us to contact you via SMS text message to remind you of future OH appointments.

Section 3: GP Details GP Name:

GP address:

Postcode:

DeclarationI declare that the information I have given is correct to the best of my knowledge. I consent to an occupational health assessment. I understand that the contents of this form are confidential to Occupational Health.

Signature       Date      

Section 4: Clinical information – to aid occupational health assessment and advice

Please indicate your current reason for shielding. Tick as many that are relevant Yes No

1 Solid organ transplant recipients 2 Specific cancers for which shielding has been advised

Please provide details of you cancer and treatment in text box below 3 People with severe respiratory conditions including all cystic fibrosis, severe

asthma and severe COPD. 4 People with rare diseases and inborn errors of metabolism that significantly

increase the risk of infections (such as SCID, homozygous sickle cell). 5 People on immunosuppression therapies sufficient to significantly increase

risk of infection. The relevant immunosuppression therapies are listed here: 6 Women with significant heart disease, congenital or acquired who are

pregnant (at any stage of pregnancy) or those who are >28 weeks pregnant7 Severe diseases of body systems, such as severe kidney disease (dialysis),

frequently relapsing nephrotic syndrome of those with a current nephrotic range proteinuria, etc.

8 People with a neurological condition that has been identified as high risk as detailed in the guidance from the Association of British Neurologists Guidance on COVID-19 for people with neurological conditions, their doctors and carers available at the following link - https://cdn.ymaws.com/www.theabn.org/resource/collection/65C334C7-30FA-45DB-93AA-74B3A3A20293/ABN_Neurology_COVID-19_Guidance_v6_9.4.20_FP.pdf

9 Multiple long term conditions/risk factors for which you have sought advice from occupational health and been advised that you are in the red risk group in the staff risk assessment

10 Other – please specify below Please provide details of your health condition in the box below with details of your current

treatment and any supplementary information you think is relevant to your current shielding If possible, please send your shielding letter to occupational health so it can be stored on your OH

records Please detail specialists’ names and hospital clinic if you are happy to share with OH

Do you have any specific questions or concerns about your health and work?

A member of the OH team will be in touch to make an initial assessment by telephone review once all the paperwork has been received.

Thank you for completing this questionnaire. You can send your completed questionnaire to us using one of the following methods:

Email to occupational.health@wsh.nhs.uk Print off your questionnaire, complete by hand and return by post with any documents to:

Risk assessment Questionnaire – Shielding Staff/Red risk group staffOh Occupational Health and WellbeingWest Suffolk HospitalHardwick LaneBury St EdmundsIP33 2QZ

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