National Association of Hospital Play Staff  

Guidelines for Professional Practice

Number 3

Risk Management

Introduction

During the 1990’s, the loss of Crown Immunity in NHS Trusts and the introduction of Crown Indemnity for NHS doctors led to many changes within the NHS. A new interest in risk management, health and safety requirements and the management of legal claims resulted. Clinical audit was introduced, and quality committees were set up.  The consultation document, ’A First Class Service’ (1997) subsequent to the government’s White Paper, ’The New NHS. Modern. Dependable’ (1997) outlines clinical risk reduction programmes and critical incident reporting as the main components of clinical governance.

The Benefits

·        Improvement in the quality of care received

·        Improved staff support and training

·        A reduction in the number of accidents to staff and patients

·        Lower insurance premiums

·        A reduction in the number of negligence claims

Hospital Play Specialists have an important part to play in managing the risks to themselves, their colleagues and their patients. Not all risk can or should be removed. For example: the use of scissors carries a certain degree of risk, but this does not mean that we should no longer use them in activities, we should however be aware of their potential for injury and introduce measures to reduce the risks. It is our duty to use our knowledge and insight into the needs of children and the environment in which we work to:-

·        assess the potential risks

·        balance the risks with the benefits

·        develop strategies to minimise the risks

·        implement and maintain risk management strategies

·        document and monitor risk management strategies

·        review adverse incidents and accidents with a no blame policy.

Categories of Potential Risk

1. Environment
    

The Playroom

• There should be no areas of disrepair, which could be harmful to children.
• The floors and surfaces should be cleaned on a regular basis.
• There should be clearly displayed information about opening hours (where applicable) and supervision. Guidelines should state who is responsible for the playroom and the play equipment out of hours.
• Windows should only open a small distance, so that children cannot climb through them.
• Cupboards containing games or toys, which have small pieces, should be locked.
• Electrical sockets should have safety covers.
• Furniture with sharp corners should be avoided, but if they exist, corners should be protected.
• All painted surfaces should be non-toxic.

The Out-door Play Area

• Access to the outside play area should be regulated, where possible.
• Clear guidelines should exist as to who has responsibility for the children whilst they use the outdoor area, and for monitoring the outdoor play equipment.
• British Standards approved impact-absorbing surfaces should be used.

2. Equipment, Chemicals and Substances

Equipment Regulations

All play equipment must conform to the EEC Toy Safety Regulations EN71. The UK also has a British Safety Standard – BS5665. These standards cover the mechanical and physical properties of a toy and the flammability and toxicity of materials used in its manufacture. All electronic toys must conform to British Safety Standard HD 271/BS EN 50088.

The Lion Mark is a symbol of quality and safety developed by the British Toy and Hobby Association (BTHA) and is only used by members of the association. Toys bearing the Lion Mark have been made to the standards currently in force in Britain and the European Community (BS 5665/EN71). The symbol is also displayed by approved Lion Mark retailers to indicate that the toys sold conform to the Lion Mark standards.

The CE mark is not a consumer mark, but a mark of conformity aimed at assisting the free movement of goods within the European Community. Toys carrying the CE mark must also have the name and address of the manufacturer printed on them.

Guidelines

• All toys should be checked for damage and cleaned on a regular basis.
• Broken or incomplete toys or equipment should be condemned and disposed of.
• The hospital electrician should check all electrical equipment in line with Trust Policy. The ward infection control policy should outline who has the responsibility for cleaning the toys that have been used by an infectious patient.
• All toys taken to neutropenic patients should be clean.
• Unless otherwise advised by the infection control department, hot water and normal detergent are adequate to wash toys, which must be dried thoroughly.
• Soft toys are a potential fire hazard.
• Soft toys carry dust, which may be harmful to asthmatics and are an infection control risk. In order that a soft toy is infection free, it must be washed at 80-90 degrees or autoclaved. Soft toys that will not withstand this process, must be disposed of.
• Soft toys that do not conform to British Safety Standards (EN71BS5665) must be disposed of.
• Battery operated toys should not be left out in unsupervised areas. When changing the batteries on a toy, all the batteries should be changed. If toys are not played with for longer than a week, the batteries should be removed to avoid damage from corrosion. Always follow the manufacturer’s instructions and recommendations.
• Balloons are a choking hazard (a large number of children die each year from inhaling deflated balloons). Be aware that some children have severe latex/rubber allergies. Latex particles are released into the air when a balloon is inflated.
• Long lengths of string or rope on pull along toys or mobiles are potentially dangerous.
• Toys with small pieces that could be swallowed, choked upon, pushed into the nose or ear must never be given to very young children. These must be kept out of reach of the under threes and children/teenagers with developmental delay, where possible in a locked cupboard.
• Glass items (bubble tubes) should be placed out of reach.
• Equipment that heats up whilst in use must be supervised at all times.
• Mobile phones should be switched off within the hospital building.
• Guidelines on the storage and use of cleaning agents, spray paint, glue, staple guns, irons and sharp objects should be adhered to.

The document ‘EH40/2000 Occupational Exposure Limits 2000’ contains a list of the maximum exposure limits and occupational standards for substances and should be used in conjunction with the Control of Substances Hazardous to Health (COSHH) Regulations 1999. 

    3. Staff

Newly employed play staff, students and volunteers should have a formal induction programme. There should be written checklists to ensure that all the relevant risk management issues are covered.

This should include:-

• Playroom and out-door play area guidelines
• Guidelines on access to the kitchen and parent’s quarters
• Location of fire exits
• Ward policy for taking patients off the ward
• Ward policies for the videoing and photograph taking of patients
• Infection control policies
• Rubbish disposal policy
• Accident/incident reporting
• Guidelines for the use of electrical equipment
•  Trust mandatory training requirements
• Play staff, who undertake the preparation and/or cooking of food as a play activity must attend basic food handling training and have regular up-dates.

Play Managers

Managers of play staff should ensure that their staff are equipped with the skills to carry out all the responsibilities outlined in their job description. Appropriate training should be provided if they are not. All staff (salaried and non-salaried) should be police checked and be screened by the Occupational Health Department. Appropriate references should be sought from their line manager in their previous   employment.

 4.  Paediatric Patients

Paediatric patients are vulnerable because of the age mix. It is often the case that younger and older children play in the same room, but using different equipment. They may not respect each other’s space or needs. The number of children accessing the play service may need to be regulated and the ratio of staff to children may need to be monitored. Special considerations should be made for children in wheelchairs or on bed-rest or who are having an I.V. infusion.

Consent forms must be signed by parents/person(s) with parental responsibility if a patient is to have their photograph taken, be filmed or recorded.  Parental written consent must also be gained if patients are to leave the ward on an organised outing. Consultant permission must be sought for such outings. All consent forms should be filed in the patient’s medical records.

A reference guide to consent for examination and treatment is available from the NHS Response Line (Tel: 0541555455)  www.doh.gov.uk/consent 

 5.   Parents, Siblings and Visiting Children

For parents and carers, a hospital admission is a time of great stress. They will have to get used to the hospital environment and the large numbers of new people they will meet, as well as take on board information about their child’s illness. This may lead to forgetfulness with regard to safety, poor compliance with instructions or aggressive behaviour towards each other and/or staff members. Parents should be given clear guidelines about the supervision of siblings and/or visiting children in line with Trust Policy. In some situations, due to infectious nature of the child’s illness, visits may need to be limited.  

 
6.       Animals

• Before purchasing an animal, careful discussion with the ward manager and infection control officer should take place. A ward or playroom pet can be a source of pleasure, however some groups of patients can be put at risk by their presence on the ward.
• Mice, rats, guinea pigs, rabbits, canaries, coldwater fish, tortoise, clawed toads and invertebrates such as stick insects are very suitable for the hospital environment.
• Golden hamsters, gerbils, mynah birds, frogs, toads and salamanders are moderately suited to the hospital environment.
• Terrapins, turtles, snakes, primates and members of the parrot family are unsuitable. Budgerigars may carry psittacosis, a lung disease, which can be transmitted to humans and are therefore unsuitable as a ward pet.
• A newly acquired animal should have a veterinary examination, which should include screening for pathogens and parasites.
• The animal should be purchased from a source recommended by the Medical Research Council’s Laboratory Animals Centre. This will ensure that the animal is free from infection and disease. The centre will give advice on caring for your pet.
• It is important that a ward pet stays in a healthy condition and is taken to the veterinary clinic when necessary. If the animal becomes ill, it must be isolated immediately and professional advice should be sought.
• In the interests of good hygiene, staff and patients should always wash their hands after handling animals.
• Any surfaces with which the animal has come into contact should be thoroughly washed down.
• A named member of staff should have overall responsibility for the care of a ward pet.

7.       Security

·        Hospital play staff, volunteers and students should adhere to local security guidelines.

·        All staff should have police clearance, an occupational health check and relevant references.

·        Entertainers, celebrities and one-off visitors must be supervised throughout their visit and must never be left alone with children.

8.       Procedures

Led by a qualified Hospital Play Specialist, play preparation for hospital procedures is in itself a risk reduction strategy, because it can eliminate the need for the use restraining techniques. It can also reduce the need for sedation and/or a general anaesthetic, thereby eliminating the medical risks associated with these. These positive outcomes can lead to a reduction in the number of complaints made to the NHS Trust. There is some evidence to suggest that good preparation can lead to a reduction in post-operative complications due to resulting reduced anxiety levels and improved coping strategies.

The safe use, storage and disposal of play preparation equipment is essential.

For further information on play preparation, refer to NAHPS Guidelines for Professional Practice, Number 5, Play Preparation and Number 6, Needle Play.

References

Health and Safety Executive website - www.hse.gov.uk

Child Accident Prevention Trust, 18-20 Farrington Lane, London, EC1R 3HA

Tel: 020 7608 3828

British Standards Institution, Linford Wood, Milton Keynes, MK14 6LE.

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