Taking steps to check slips and trips

Health and Safety Executive (HSE) statistics show that slips and trips remain the single most common cause of major injury in UK workplaces, resulting in almost 11,000 major injuries every year. Taken across all sectors, they account for 38% of all major injuries, and are the second biggest cause of injuries lasting over three days.  

Furthermore, slip and trip injuries cost UK employers £512 m, while the annual financial cost to the UK health service alone is reckoned to be £133 m. Aside from the financial costs, which may in some health sector instances include the cost of litigation, the HSE points out that the human cost of a serious fall may not only include pain and loss of income, but equally reduced quality of life, significant worry and stress. HSE data suggests, additionally, that 95% of all major slip and trip injuries result in broken bones while, in the health sector, such accidents account for 8% of all fatalities among the public. Plenty then for health estates managers to chew on.  

Two-year HSE campaign  

To combat what it dubs the “everincreasing number of slip and trip accidents in the health sector”, the HSE initiated a two-year campaign in the summer of 2005 to help galvanise those running healthcare facilities into taking action. During the campaign HSE ran a series of seminars to provide guidance and information, and produced publicity and poster packs. HSE inspectors and other staff also visited healthcare establishments across Britain to assess standards, offer advice and enforce applicable legislation.  

Mark Thomas, a health and safety policy adviser for the HSE Slips and Trips Programme, says: “HSE provides ongoing advice on flooring suitability and safety to Trusts and regularly assesses hospital premises, but we feel specific campaigns can have a very positive impact. In this campaign we successfully gathered some 900 delegates UK-wide at 23 regional events, many of them health estates managers and Trust health and safety personnel.  

“The areas covered range from undertaking regular flooring risk assessments to the importance of appropriate floor cleaning and slipresistant footwear. Feedback was excellent, and we are now writing to all the delegates asking them how, and how successfully, they have implemented our advice. We hope from the response to be able to publish more information on good practice for everybody’s benefit.  

“We also provided input into the revision of the NHS guidance document, HTM 61, on flooring, to incorporate the latest information on preventing slips when fitting new floors. For example, we suggested some relevant ‘tweaks’, such as the need to consider the safety implications of staff walking from a foreseeably wet area like an autoclave room, with safety flooring, to a corridor outside fitted with smooth vinyl.”  

Likelihood of legal action  

While the HSE monitors flooring safety in many sectors, it says focusing on slips and trips in the healthcare sector is “especially important” because injuries to healthcare workers and the public are “of concern”, and there is a likelihood that those injured would pursue legal action too. Indeed the cost of civil claims for slip and trip injuries to employees and the public in or on NHS premises in England reported to the NHS Litigation Authority over the last four years exceeds £25 m. Typical claims average around £5,000, but some have hit £600,000.  

Mark Thomas says: “Slip and trip injuries among hospital staff and patients are a big financial drain; it’s interesting to note too that the average NHS hospital has far more patients at any one time being treated for slip and trip injuries than for injuries from road accidents.” While the HSE’s statistics demonstrate just how significant an issue slip and trip accidents are for the healthcare profession, the HSE claims the number can be reduced through “planning and positive management during refurbishment and new build, together with good housekeeping”. It says accidents are “not an inevitable part of the health industry – they can, and should be, prevented”.  

Improved ‘education’ of architects/designers  

One area Mark Thomas says the HSE believes would benefit from more attention is “improved education” of designers and architects in what constitutes fit-forpurpose flooring. He says: “While some do a first-rate job, there is a lot of misinformation around, for instance about the best ways to test flooring slip resistance, while general flooring standards in Europe are not as high as we would like. The result is that slips and trips are still far too common. To better brief such personnel we are keen to offer another seminar on slips and trips for those responsible for new build or refurbishment in the NHS from the designer/architect community.” In an article in Health Estate Journal’s May 2007 issue, “Slip and trip prevention needs full attention”, we examined how thorough, frequent and controlled floor cleaning can prevent many falls. Indeed the HSE says slippery/wet surfaces caused both by water and other fluids, and contamination from dry substances and dust, are among the biggest causes of healthcare sector slip and trips. However, obstructions – permanent or temporary, uneven surfaces, and changes of level, such as unmarked ramps – can all contribute.  

Legislative requirements  

While we will not revisit the earlier advice, it is vital that health estates managers, hospital designers and architects, and equally contractors and sub-contractors building new, or refurbishing existing, healthcare facilities, are aware of the main legislative requirements which place an onus on all parties to minimise slip and trip risks.  

Firstly, under the Health and Safety at Work etc Act of 1974, employers must “ensure their employees and anyone else who could be affected by their work (such as visitors, members of the public and patients) are kept safe from harm and that their health is not affected”. This means controlling slip and trip risks to ensure people do not slip, trip and fall. In addition, the Act stipulates that employees use any safety equipment provided and “must not cause danger to themselves or others”. Manufacturers and suppliers of cleaning solutions, for instance, must ensure that their products are safe and “provide information about appropriate use.”  

Building on this Act, the Management of Health and Safety at Work Regulations 1999 include duties on employers to assess risks (including those from slips and trips) and specify that they must, “where necessary”, take action to safeguard health and safety. The legislation specifies the five steps required for effective risk control arrangements and employee duties, and emphasises the need for training and consultation with safety representatives. The five steps considered essential for risk assessment are to: identify the hazards; decide who may be harmed and how; evaluate the risks and decide if the existing precautions are adequate; record the significant findings, and review the assessment periodically.  

Also important are the Workplace (Health, Safety and Welfare) Regulations 1992, which “require the floor surface to be suitable for the workplace and workplace activity, kept in good condition and free from obstructions”. Floors are deemed “suitable” by “not being slippery so as to expose any person to a risk to their safety” and must also have “effective drainage”.  

The Regulations say preventing contamination rather than increasing the slip resistance to counteract it is “clearly preferable”. However, the HSE says very small levels of contamination (“a single drip in some cases”) can lead to “drastic increases in slipperiness”, so contamination prevention must be very thorough.  

Under the same Regulations suppliers of equipment, floor treatment substances and slip-resistant shoes must “ensure, so as far as is reasonably practicable, the inherent safety of their products and provide information to users”. Floor construction must also “have no holes, or slope, or be uneven, so as to expose a person to a risk” and be “free of obstructions and from any article which may cause a person to trip”. Floors must also “not have accumulated waste materials, except in suitable receptacles”.  

HSE’s more general slips and trips prevention advice emphasises that among the most common causes of slips is floor contamination from a variety of sources, including cleaning materials, dirt or wet shoes and clothing, wet and/or mud in outside areas, dry contamination such as dust, powders and polythene bags left on floors, wind-driven rain, sleet and snow through doorways, and condensation.  

Eliminate contamination ‘in the first place’  

The Executive says the key is to eliminate contamination in the first place, primarily by maintaining equipment to prevent leakage, installing suitable entrance matting systems, placing entrances to suit the prevailing weather (only an option during a building’s initial design) and erecting effective entrance canopies. Those responsible for flooring safety and maintenance should also prevent contamination becoming deposited on walking surfaces by “using dry methods for cleaning floors”, and using suitable entrance matting to ensure clean, dry incoming footwear.  

Mark Thomas wonders why so many hospital entrances, subject to the vagaries of the British weather, “have nice slippery flooring in the entrances.”  

Where contamination has occurred, spillages should, the HSE says, be immediately cleared up, any leaks promptly repaired, the area of contamination limited, and access to contaminated areas restricted. All common sense really. While the relevant legislation places considerable emphasis on ongoing cleaning and maintenance, it is equally important that whoever specifies flooring, whether for refurbishment or new build, ensures the selected material does not have inherent properties that make falls likely. A common mistake is to specify flooring with too low a slip resistance for “foreseeably wet areas”.  

Initially, it was thought that the characteristics of floor surface materials needed for satisfactory slip resistance were difficult to assess. However, HSE’s technical information sheet, Assessing the slip resistance of flooring, says research undertaken on its behalf by HSL, in conjunction with the UK Slip Resistance Group and the British Standards Institute, has shown this is not the case.  

The sheet specifies that “the slipperiness of flooring materials can be accurately assessed by using commercially available, portable scientific test instruments”.  

The key instruments and procedures referred to are the “pendulum co-efficient of friction” (CoF) test and the surface microroughness meter.  

According to flooring manufacturer Altro, which supplies safety flooring to the healthcare sector that exceeds the minimum slip resistance standards of the HSE and aims to meet all other international health and safety standards: “In most circumstances both pendulum CoF and surface microroughness readings are required to give an accurate indicator of floor surface slipperiness”.  

Useful advice booklet  

Itself a UK Slip Resistance Group member, Altro’s booklet Slips and Trips: the essential modern guide to prevention, sets out the latest facts and figures on slips and trips, suggests how flooring specifiers or users can prevent such incidents, and gives details on the background to, and workings of, both the pendulum test and the surface microroughness meter.  

This booklet, and the relevant HSE guidance, explain that the pendulum used for the “pendulum CoF” test was designed to simulate the action of a slipping foot. The test method uses a swinging, dummy rubber-soled heel which sweeps over a set area of flooring in a controlled manner. The floor’s slipperiness has a direct, measurable effect on the resulting pendulum value (or pendulum test value – PTV). The pendulum test has proven to be “reliable and accurate”, leading to its adoption as the standard HSE test method for the assessment of floor slipperiness in dry, wet and contaminated conditions. However, the HSE stresses it does need a “suitably trained and competent person” to operate it and interpret the results – particularly where the pendulum is to be used on heavily profiled flooring materials, stair treads and nosing.  

To provide a clear indication of any floor’s slipperiness, the pendulum values are classified in terms of slip risk as follows: high: 0-24; moderate: 25-35 and low: 36+. The minimum HSE guideline for slip resistance in potential wet areas is a pendulum measurement of 36 or above.  

Surface microroughness measurement  

The other method for determining floor slipperiness involves measuring the surface microroughnness of the flooring. Roughness measurements can also be used to monitor changes in floor surface characteristics such as those occurring via wear and tear. The test, which uses a microroughness meter that measures in “Rz” values, is recommended for use in tandem with the pendulum test. Another tool to help with carrying out slip risk assessments is the HSE’s Slips Assessment Tool (SAT) software (downloadable from the HSE’s website: www.hse.gov.uk/slips/information.htm) which, if used in conjunction with the microroughness meter, enables users to produce a quantitative estimate of slip risk on different flooring types.  

Using the tool first requires collection of detailed information about the working area, i.e. what material it is made from and what cleaning systems are used, plus data on the type and amount of contamination envisaged. For a true estimate users must take a series of measurements at the test location using the small microroughness meter. On completion they will gain a “slip risk classification”, which should, Altro says in its booklet, “give an accurate indication as to the potential for slip”. While designed to assist decision-making when considering the risk of slipping in a defined area, Altro says the SAT should not be relied on alone. Pendulum test data should also be sought from the flooring manufacturer. However, one of the SAT’s useful features is the ability to change the variables entered to identify what factors, such as a change of cleaning regime, might lower the slip risk. To help flooring specifiers the HSE sets out minimum suggested Rz surface microroughness values at which floors should still have a low slip potential when contaminated with different substances. These range from 20 µm where there is a risk of contamination from clean water, coffee, and soft drinks, to 45 µm where potential contaminants include soap solution and milk, to above 70 µm where contamination with gear oil or margarine is possible.  

Although some other tests (such as ramp tests, where test subjects walk forwards and backwards over a contaminated sample on an incline made gradually steeper until they slip) are used by flooring manufacturers, the pendulum CoF test and surface microroughness measurements appear generally to be considered the most reliable methods for flooring specifiers in the UK healthcare sector for classifying the slipperiness of a particular flooring material. The HSE’s Mark Thomas says: “Overall there may be up to 100 different friction tests for floor surfaces throughout the world, but there are only a small number that we have confidence in”.

Floors need regular checking  

Alongside the need to clean flooring in an appropriate manner, the HSE and indeed the Workplace (Health, Safety and Welfare) Regulations 1992 specify that lighting should enable people to see obstructions and potentially slippery areas so they can work safely. Trusts should “replace, repair or clean lights before levels become too low for safe work”. Floors also need to be checked for loose finishes, holes and cracks, while the HSE says specifiers and healthcare facility operators should seek specialist advice when choosing a floor for “difficult conditions”.  

Health estates managers, architects, designers and buildings/services contractors should also be familiar with the main provisions of the updated Construction (Design and Management) Regulations 2007, which came into force on 6 April 2007.  

From that date, the regulations stress that a building’s designer has a legal duty to ensure the safety of people using a building and must:  

More onus on the specifier  

The updated CDM Regulations now put more of an onus on the specifier to ensure that any products chosen are fit for purpose when the building is open for the public. This, observers say, will undoubtedly lead to a rise in the number of architects both considering and using safety flooring as a precaution, to avoid landing themselves in the dock. However, while architects may well specify flooring “fit for purpose” from a safety standpoint, what happens if the healthcare professional, or a contractor, opts to change the architectspecified flooring? Alan Sutherland, of Altro’s Health and Facilities Management team, says this “can happen quite frequently, often when cost savings have to be made”.  

Risk of being ‘hauled before the courts’  

He says: “If they fail to ensure the type of flooring chosen is fit-for-purpose, they too could be hauled before the courts if there is an accident following the installation. With the new CDM Regulations stating that specifiers should ‘avoid foreseeable risk to the health and safety of any person using a structure designed as a workplace’ (formerly the designer was obliged to ‘avoid safety risks in building, structural maintenance and demolition’), it is even more important that appropriate flooring, which may in some cases mean safety flooring, is installed in all the right places, and that regular risk assessments are undertaken by health estates managers and their staff.”  

“All parties involved in flooring specification, installation and supply, from the architect, designer, main contractor and flooring sub-contractor to the hospital estates manager, must be aware they could be liable should an individual bring a claim related to a slip or trip caused by a flooring deficiency.”  

As Ron Austin, Altro’s UK business development manager, puts it: “CDM 2007 takes the building client from a position of near immunity to one where they could end up in the dock over a fatal accident.”  

Landmark legal case  

One recent legal case demonstrates not only the importance of taking one’s health and safety responsibilities as regards flooring seriously at all times, but also the potential for established legal thinking and precedent to be effectively swept away – in this case to the considerable discomfort of the defendant involved. In Ellis v Bristol City Council 2007, a case brought under the Workplace Regulations 1992, the claimant, a care assistant at a home for the elderly run by the defendant, slipped in a pool of urine left in a main corridor by an elderly resident.  

At the initial hearing it was argued that the defendant, Bristol City Council, knew that residents regularly urinated in the corridor involved, an occurrence which had already caused a number of accidents. However, the defendant said it had a good system of inspection and cleaning in place, alongside risk assessments, warning notices and two non-slip mats positioned in the worst hit areas.  

Pleading her case under regulation 12 of the 1992 Regulations, the claimant alleged that the flooring was unsuitable for its purpose because it was often urinated on and became slippery when wet. Paragraph 93 of the Code of Practice in relation to Regulation 12 provided that surfaces of floors likely to get wet “should be of a type which do not become unduly slippery and a slip-resistant coating should be applied when necessary”. However, the Code and alleged breach of practice was disregarded by the judge “because it was not a matter specifically pleaded or dealt with in the evidence”. The judge dismissed the claim on the basis that the strict liability in regulations 12 (1) and 12 (2) related to the construction of the floor surface and not to a “transient hazard”.  

When the case went to the Court of Appeal, however, the appellant referred to provisions in Regulation 12 that state: