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					                                                           NSPCT
                                                    Corporate Risk Register




North Somerset Primary Care Trust Corporate Risk Register April 2009 - March 2010

Legend

Likelihood                                                                      Consequences
                                                 Negligible 1      Minor 2    Moderate 3 Major        4     Catastrophic
                                                                                                                 5

Almost Certain                              5          5              10           15            20             25
Likely                                      4          4              8            12            16             20
Possible                                    3          3              6            9             12             15
Unlikely                                    2          2              4            6             8              10
Rare                                        1          1              2            3             4              5




CB = Chris Born
MK = Max Kammerling
JG = Jeanette George
JC = Julie Clatworthy
MH = Mary Hutton                                                                                          ###################
PB = Penny Brown




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Likelihood

       Likelihood       Description
                        Will undoubtedly occur, possibly frequently
  5    Almost Certain
                        (several times per year)
                        Will probably occur but it is not a persistent
  4    Likely
                        issue (annually)
  3    Possible         May occur occasionally (every 10 years)
                        Do not expect it to happen but it is possible
  2    Unlikely
                        within 50 years
                        Cannot believe that this will ever happen in 50
  1    Rare
                        years

Consequence

       Consequence      Actual Or Potential Impact                        Actual Or Potential Impact On The Organisation
                        Death                                              l International adverse publicity, loss of confidence in the organisation
  5    Catastrophic     Organisational Disaster                            l Extended service closure
                                                                           l Litigation >£million
                        Major permanent harm                               l National adverse publicity/major loss of confidence in the service
                                                                           l Temporary service closure
  4    Major
                                                                           l Litigation >£500,000
                                                                           l Increased length of stay >15 days
                        Semi-permanent harm (up to 1 year)                 l Local adverse publicity/moderate loss of confidence
  3    Moderate                                                            l Litigation £50k-£500k
                                                                           l Increased length of stay 8-15 days
                        Non-permanent harm (up to 1 month)                 l Litigation <£50k
  2    Minor                                                               l Increased length of stay 1-7 days
  1    Negligible       Negligible harm                                    l Minimal impact, no service disruption
                                                                                                                                    NSPCT
                                                                                                                             Corporate Risk Register


                                           Corporate                                                                      Current        Expected                                                Lead                       Completion
       Ref No     Date of Entry   BAF No                 Risk                             Consequence    Likelihood                                    Action Required                                     Date of Review                Change note
                                           Objective                                                                       Risk            Risk                                                 Director                      Date
Strategic Development (ex Commissioning Services) Risks including those transferred from other Directorates
                                                         Inability to reduce the under                                                                 RG to liaise with public health to get
                                                         75 Cardiovascular Mortality                                                                   figures on current status and
    SD013/2008       Sep-08         8      Integration   Rate                                  3              4               12              9        projected with current projects            JG          Dec-09          May-10
                                                                                                                                                       underway
                                                         Dental activity targets not                                                                   Vital signs target 09/10 increases -
                                                         delivered                                                                                     will require additional investment to
                                                                                                                                                       be met in line with operational plan.
    SD019/2008       Aug-09         1       Targets                                            3              4               12              9        Need to revisit commissioning plan         JG          Dec-09          Mar-10
                                                                                                                                                       for service.
                                                                                                                                                       Vital Signs target


                                                         Difficulty in accessing                                                                       Contract awarded, new provider from                                               Updated November 09
                                                         domiciliary care providers in                                                                 01/12/09.
    SD017/2009       Mar-09         1       Targets      parts of North Somerset,              3              4               12              6                                                   JG          Dec-09          Mar-10
                                                         notably Pill and the
                                                         surrounding areas.
                                                         CHC referral rate increasing                                                                  Continued close monitoring of                                                     Description of risk revised in November 2009.
                                                         through 09/10 possibly due                                                                    waiting list figures
                                                         to more people being aware                                                                    Review of financial provision set
                                                         of CHC support. Risk that,                                                                    aside for Free Nursing Care (FNC)
                                                         despite in depth work to                                                                      cases that could meet the eligibility
                                                         assess likely numbers                                                                         criteria for Continuing Health Care
    SD018/2009       Mar-09         4       Finance      eligible for CHC, greater             3              5               15             15        (CHC).                                     JG          Dec-09          Mar-10
                                                         number may be eligible than
                                                         predicted and will adversely
                                                         impact on budgets and staff
                                                         workloads.



                                                         There have been difficulties                                                                  Continued recruitment efforts                                                     Requires adjustment of completion date. JG
                                                         in recruiting nurses with the                                                                 particularly making use of the current                                            to advise
                                                         appropriate level of skills to                                                                jobs market which may increase the
    SD019/2009       Mar-09         1       Targets      be CHC Assessors for                  3              4               12              9        number of applicants                       JG          Dec-09          Nov-09
                                                         patients with Learning
                                                         Disabilities.

                                                         Transforming Community                                                                        Ongoing engagement of community
                                                         Services Programme:                                                                           services staff
                                                         Impact on Provider Services                                                                   Engagement with trades union
                                                         Workforce of potential                                                                        representation
                                                         changes to structure.                                                                         Provider Services integral part of
                                                         Clinicians and managers                                                                       Project Board and Project Team
                                                         within NSPCT Provider                                                                         New AD in post September 2009
    SD031/2009       Apr-09         1       Targets                                            3              4               12              6                                                   JG          Dec-09          Mar-10
                                                         Services will be undergoing
                                                         a period of considerable
                                                         change and uncertainty
                                                         which may impact on morale
                                                         and staff retention.


                                                         NS ability to deliver the SHA                                                                 Minimal investment as outlined in
                                                         SF for LD services: People                                                                    self-assessment Action Plan
                                                         with learning disabilities’                                                                   LES put in place for 09/10 to improve
                                                         health needs will go                                                                          access to primary care services.
                                                         undiagnosed & untreated                                                                       Investigation into patient safety
                                                         which may result in poor                                                                      cases completed.
                                                         health and potential                                                                          Four deaths under investigation.
    SD032/2009       Apr-09         1       Targets                                            3              4               12              9                                                   JG          Dec-09         Ongoing
                                                         emergency admissions to                                                                       Report to Board Sep 09.
                                                         hospital. People with LD will
                                                         be discriminated against in
                                                         hospital setting and receive
                                                         poor treatment.


                                                         Swine flu pandemic planning                                                                   Suspending all non-core business
                                                         deflects from core PCT                                                                        and focus resources on high priority,
                                                         business within                                                                               high risk projects only.
    SD033/2009       Apr-09         1                    Commissioning, particularly           3              4               12              9                                                   JG                         Ongoing
                                            Targets                                                                                                                                                           Monthly
                                                         Primary Care and
                                                         Procurement resulting in
                                                         failure of targets.




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                                                                                                                                      NSPCT
                                                                                                                               Corporate Risk Register


                                            Corporate                                                                       Current        Expected                                                Lead                       Completion
       Ref No     Date of Entry   BAF No                   Risk                             Consequence    Likelihood                                    Action Required                                     Date of Review                Change note
                                            Objective                                                                        Risk            Risk                                                 Director                      Date
                                                           GP Access - Not meet SHA                                                                      Under review                                                                      Currently being assessed and controls put in
                                                           targets due to work                                                                                                                                                             place.
    SD043/2009       Sep-09         1         Targets      pressures in primary care             3              4               12             12                                                   JG          Ongoing         Mar-10
                                                           team.

                                                           Clevedon Community                                                                            Alder King and David Kent Architects
                                                           Hospital - Planning                                                                           appointed to do the work to get to
                                                           permission not achieved on                                                                    PP. Project workstreams identified to
    SD044/2009       Oct-09         8       Inequalities   preferred site/s before               4              4               16             16        work with them to ensure                   JG          Dec-09          Mar-10
                                                           financial deadline                                                                            functionality and affordability.


                                                           Clevedon Community                                                                            Under review                                                                      Currently being assessed and controls put in
                                                           Hospital - inability to                                                                                                                                                         place.
    SD045/2009       Oct-09         8       Inequalities   purchase site within budget           3              4               12             12                                                   JG          Dec-09          Mar-10
                                                           by 31 March 2010 deadline


                                                           Longton Grove, Graham                                                                         Review of existing scheme. Aldi
                                                           Road, New Court relocation                                                                    proposal not proceeding. Focus on
                                                           Weston site - There is a risk                                                                 finding site. Project Group to raise
                                                           that access to primary care                                                                   profile of difficulty in finding site.
                                                           services is reduced over the                                                                  HOSP discussion; closer working
                                                           the next five years and that                                                                  with LA. Once site found to be taken
                                              Strategic    the viability of two practices                                                                forward as 3rd party development.
                                            Framework; is jepordised unless primary                                                                      Current budget allocated to scheme.
    SD046/2009       Oct-09         8         tackling     care facilities are developed         4              3               12              9        Short term proposals to ensure             JG          Dec-09          Mar-10
                                           inequalities in within the centre of Weston.                                                                  continued viability
                                               health;     This would lead to
                                                           decreased levels of care in a
                                                           high health need area and a
                                                           loss of reputation with key
                                                           stakeholders,



                                                           Wrington Vale relocation -                                                                    Under review                                                                      Currently being assessed and controls put in
                                                           PCT taken to Judicial                                                                                                                                                           place.
    SD047/2009       Oct-09         8       Inequalities   Review & risk to continuity of        4              4               16             12                                                   JG          Dec-09          Mar-10
                                                           service in area is medium
                                                           term
                                                           Risk of significant overspend                                                                 Clarification of SHA position sought
                                                           on IAPT due to DH decision                                                                    and confirmed. Provider informed to
                                                           to cease funding.                                                                             hold vacant positions. Meeting
    SD048/2009       Oct-09         4        Finance                                             3              5               15             15        arranged with Provider to look at          JG          Dec-09          Mar-10
                                                                                                                                                         ways to reduce spend and maintain
                                                                                                                                                         targets.

Finance & Performance Risks including those transferred from other Directorates
                                                           Maintain a 4 hour maximum                                                                     FBC requires Weston to move                                                       Residual risk increased from 8 to 12 on
                                                           wait in A&E from arrival to                                                                   location in Jan 2010. Major risk to                                               reassessment
                                                           admission, transfer or                                                                        4hr target. UH Bristol & NBT
    RP001/2009       Sep-09         1         Targets      discharge.                            4              3               12             12        underperforming in recent weeks.           MH          Monthly         Mar-10
                                                                                                                                                         Daily reports on performance
                                                                                                                                                         received from NBT & UHB .
                                                                                                                                                         Performance monitored daily.

                                                           All ambulance trusts to                                                                       Ongoing monitoring of performance                                                 Residual risk decreased from 12 to 6.
                                                           respond to 95% of category                                                                    (monthly, weekly and daily) to                                                    Removal requested.
                                                           B calls within 19 minutes.                                                                    determine performance against
                                                                                                                                                         standards; agree a plan for
                                                                                                                                                         escalation when ambulances
                                                                                                                                                         backed up at Weston; ensure all
    RP004/2009       Sep-09         1         Targets                                            3              3               9               6        patients admitted to EAU where             MH          Monthly         Mar-10
                                                                                                                                                         possible; develop further plan to
                                                                                                                                                         reduce turnaround times.
                                                                                                                                                         Performance severely hindered by
                                                                                                                                                         the number of ambulance handover
                                                                                                                                                         delays at all acute trust in the area.

                                                           No ambulance handover                                                                         Action plan in place for all
                                                           times at emergency                                                                            ambulance response targets.
    RP009/2009       Sep-09         1         Targets      departments will be greater           3              5               15             15        Performance against revised action         MH          Monthly         Mar-10
                                                           than 15 mins by March 2010.                                                                   plan not improved performance.




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                                                                                                                                         NSPCT
                                                                                                                                  Corporate Risk Register


                                             Corporate                                                                         Current        Expected                                                Lead                       Completion
       Ref No      Date of Entry   BAF No                   Risk                               Consequence    Likelihood                                    Action Required                                     Date of Review                Change note
                                             Objective                                                                          Risk            Risk                                                 Director                      Date
                                                            Maintain a maximum wait of                                                                      Action plan has been formulated and
    RP014/2009        Sep-09         1         Targets      13 weeks for an outpatient              3              4               12             12        will be implemented for 2009 / 2010        MH          Monthly         Mar-10
                                                            appointment.

                                                          Clearly link contract                                                                             Contract monitoring team established
                                                          monitoring reports with MSK,                                                                      and looking at this area
                                                          Community matrons , ICRT
                                            Standards for and ATC Schemes on an
    RP038/2009        Sep-09         2                                                              4              3               12              8                                                   MH          Monthly         Mar-10
                                            Better Health ongoing basis to include with
                                                          suite of reports.


                                                            Inability to break even due to                                                                  Continuous monitoring of recovery                                                 Current risk increased from 8 to 12
    RP056/2009        Sep-09         4        Finance       overcommitment of                       4              3               12             12        plan to increase savings at executive      MH          Monthly         Mar-10
                                                            resources                                                                                       level
                                                            Inability to stay within agreed                                                                 Action plan in place
                                                            acute activity levels through
    RP060/2009        Oct-09         4        Finance       delivery of RUM Schemes                 4              4               16             12                                                   MH          Monthly         Mar-10


                                                            Inability to break even due to                                                                  Strengthening of contract monitoring                                              Current risk increased from 12 to 16
                                                            over performance of SLAs
    RP063/2009        Oct-09         4        Finance                                               4              4               16             16                                                   MH          Monthly         Mar-10


                                                            Risks associated with the                                                                       Strengthen cross directorate analysis                                             Current risk increased from 12 to 16
                                                            portfolio of services                                                                           of investment proposals.
                                                            commissioned through the                                                                        Engage fully with Specialised
                                                            South West Specialised                                                                          Commissioning Team on refining
    RP065/2009        Oct-09         4        Finance       Commissioning Group. In                 4              4               16             16        proposal                                   MH          Monthly         Mar-10
                                                            particular, the risks related to                                                                Assess reasons for spend above
                                                            the proposed level of                                                                           benchmark.
                                                            investment.

                                                            Some patients whose needs                                                                       NHSNS to collate info from all PCTs                                               Current risk increased from 9 to 15.
                                                            are high cost. Lack of                                                                          in SW re which providers are being                                                Controls & assurance being assessed.
                                                            suitable providers,                                                                             used to deliver these placements.
    RP066/2009        Oct-09         4        Finance       complexity of needs and                 3              5               15             15        Negotiations in collaboration with         MH          Monthly         Mar-10
                                                            size of contracts affords                                                                       other PCTs to achieve better value
                                                            providers negotiating                                                                           for money.
                                                            strength (CHC)

                                                            Contribute to the SHA                                                                           QUIPP being incorporated into                                                     Current risk increased from 10 to 16
                                                            ambition to improve the                                                                         Operational Plan and Strategic
                                                            productivity of clinical                                                                        Framework. Action plans still being
                                                            activity by at least £700                                                                       developed.
                                              Service
    RP059/2009        Sep-09         6                      million per annum by 31                 4              4               16             16                                                   MH          Monthly         Mar-10
                                             Redesign
                                                            March 2014, with 50% of the
                                                            potential achieved by 31
                                                            March 2011

                                                            ECP and paramedics:                                                                             Plan agreed to enable North
                                                            unable to monitor impact of                                                                     Somerset ECPs to work more closely
                                                            ECP Activity as PCT does                                                                        with provider services. GWAS using
                                              Service       not understand relationship                                                                     ECPs as first responders but not
    RP068/2007        Oct-09         6                                                              3              4               12             12                                                   MH          Monthly         Mar-10
                                             Redesign       between conveyance rate                                                                         reducing conveyance. May remove
                                                            and activity                                                                                    funding.


Public Health Risks including those transferred from other Directorates
                                                            Fail to deliver a                                                                                                                                                                 This was rated as 12 as we expected to
                                                            comprehensive CAMHS                                                                             Will amend the Proposal from WAHT                                                 mitigate the risk due to the appointment of a
                                                            across NS with increased                                                                        re increasing consultant psychiatry                                               locum consultant. However he resigned after
    PH008/2008        Apr-07         8       Inequalities   integrated working between              4              4               16             12        provision for ET meeting 9.11.             MK          Dec. 09         Apr-10     only one day and the residual risk was
                                                            agencies                                                                                                                                                                          increased to 16. Additional investment agreed
                                                                                                                                                                                                                                              by ET has allowed an additional part time
                                                                                                                                                                                                                                              consultant to be advertised for.

                                                            Failure to achieve LAA                                                                          Action plans in place - paper taken to                                            Met targets for mental health users. Action
                                                            target in respect of smoking                                                                    Health and Wellbeing Strategic                                                    plan may allow achievement of 60% of target
                                                            in target groups                                                                                Partnership - discussions with                                                    and access to part of reward grant- reducing
                                                                                                                                                            Central Ward Regeneration Team re                                                 severity of consequence
    PH009/2008        Apr-07         8       Inequalities                                           3              5               15             12                                                   MK          Dec. 09         Mar-10
                                                                                                                                                            link with return to work schemes -
                                                                                                                                                            incentive scheme established in
                                                                                                                                                            South Ward




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                                                                                                                                    NSPCT
                                                                                                                             Corporate Risk Register


                                          Corporate                                                                       Current        Expected                                                  Lead                       Completion
       Ref No    Date of Entry   BAF No                  Risk                             Consequence    Likelihood                                    Action Required                                       Date of Review                Change note
                                          Objective                                                                        Risk            Risk                                                   Director                      Date
                                                         Inability to reduce smoking                                                                   Action plan reviewed monthly                                                        as above
                                                         in the Over 16s and achieve
                                            Patient &
    PH010/2008      Apr-07         9                     stated target of people who           4              3               12              9                                                     MK                          Mar-10
                                             Public                                                                                                                                                             Dec. 09
                                                         quit at the 4 weeks
                                          Involvement
                                                         recordable target date

                                                         Failure of North Somerset                                                                     Implement the Alcohol Strategy using
                                                         Alcohol Strategy to deliver                                                                   funding for alcohol services identified
                                            National     alcohol admissions targets                                                                    in the operational plan - insufficient
    PH011/2008      Apr-07         7        Service      in LAA and Vital Signs                4              4               16             12        resources to deliver alcohol                 MK          Dec. 09         Mar-10
                                          Frameworks                                                                                                   treatment service. Use EOI process
                                                                                                                                                       to identify further funds

                                                         Inability to achieve reduction                                                                Action Plan on Childhood Obesity
                                                         in childhood obesity                                                                          has been refreshed and extra
                                            National
    PH012/2008      Apr-07         7                                                           4              3               12              8        resource identified in operational           MK                          Mar-10
                                            Service                                                                                                                                                             Dec. 09
                                                                                                                                                       plan Negotiation taking place with
                                          Frameworks
                                                                                                                                                       SHA re targets in the trajectory

                                                         Inability to increase the                                                                     Effect of mass swine flu vaccination                                                Current risk has been increased from 12 to 16
                                                         proportion of children who                                                                    on these targets is currently unknown                                               as numbers receiving HPV vaccine have
                                                         have completed                                                                                There is a reduction in uptake of                                                   fallen to 69% against the target of 90%
                                                         recommended                                                                                   HPV following media response to
                                            Patient &    immunisations                                                                                 unexplained death
    PH013/2008      Jun-09         9         Public                                            4              4               16             16        There will be a National Campaign to         MK          Dec. 09         Mar-10
                                          Involvement                                                                                                  increase confidence and our school
                                                                                                                                                       nurses are also working with schools
                                                                                                                                                       and parents (open evenings,
                                                                                                                                                       newsletters etc.)


                                                         Failure to increase                                                                           EOI has been submitted for
                                            Patient &    prevalence of breast feed in                                                                  breastfeeding coordinator and also to
    PH014/2008      Jun-09         9         Public      at 6-8 Weeks                          3              5               15             12        increase front line service capacity         MK          Dec-09          Mar-10
                                          Involvement

                                                         Failure to reduce the                                                                         Clear action plan in place - progress                                               Current likelihood remains high, but
                                                         prevalence of Chlamydia                                                                       is slow                                                                             consequences reduced as the target is
    PH015/2008      Mar-08         8      Inequalities                                         3              5               10              8        EOI submitted to fund increase in            MK          Dec-09          Mar-10     proving challenging to all health communities.
                                                                                                                                                       testing next year                                                                   Now below threshold, so removal requested


                                                         Failure to achieve target of                                                                  Baseline data collected.                                                            Have implemented actions.
                                            National     number of Women receiving                                                                     Patient leaflet produced to                                                         Have increased number seen to 98% but a
    PH016/2008      Mar-08         7        Service      maternity assessment by 12            3              4               12              9        encourage early booking - CQUINS             MK          Dec-09          Mar-10     100% target is impossible to reach so
                                          Frameworks     weeks                                                                                         target set                                                                          changed initial risk (12 to 9) and the residual
                                                                                                                                                                                                                                           risk (9 to 6) to reflect this.
                                                          Failure to achieve target for                                                                Portishead Primary Care Resource                                                    Difficult to mitigate as risk is too wide and all
                                                         reducing All Age All Cause                                                                    Centre in place.                                                                    encompassing. Have raised the likelihood as
                                                         Mortality Rate and the                                                                        Procurement of GP led Health                                                        latest figures show the gap in All Age All
                                                         difference between groups                                                                     Centre complete drop in for Central                                                 Cause Mortality is widening - need to invest in
                                                                                                                                                       Weston planned to open in January                                                   targeted prevention initiatives to reduce this
    PH017/2008      Mar-08         8      Inequalities                                         3              4               12             12        2010.                                        MK          Dec-09          Mar-10     gap
                                                                                                                                                       Procurement of alternate provider
                                                                                                                                                       Medical Service practice for Worle /
                                                                                                                                                       West Worle - planned opening in
                                                                                                                                                       January 2010

                                                         Inability to reduce health                                                                    Needs assessment and investment                                                     Controls have limited impact as the mortality
                                                         inequalities as measured by                                                                   in projects and programmes                                                          is already low and small fluctuations result in
    PH021/2008      Mar-08         8      Inequalities   infant mortality children             3              4               12              9        designed to target those with poorest        MK          Dec-09          Mar-10     large changes. Family Nurse Partnership now
                                                                                                                                                       health                                                                              in place so residual risk reduced


                                                         Inability to achieve reduction                                                                Audit completed.                                                                    Residual risk increased from 12 to 15 on
                                                         in under 18s conception rate                                                                  Plan in place to address gaps in                                                    reassessment.
                                                                                                                                                       provision.
                                                                                                                                                       New staff recruited.
    PH022/2008      Mar-08         8      Inequalities                                         3              5               15             15        EOI submitted for Long Acting                MK          Mar-10          Mar-10
                                                                                                                                                       Reversible Contraception service -
                                                                                                                                                       this will not impact on this target this
                                                                                                                                                       year




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                                                                                                                                      NSPCT
                                                                                                                               Corporate Risk Register


                                            Corporate                                                                       Current        Expected                                                   Lead                       Completion
       Ref No     Date of Entry   BAF No                  Risk                              Consequence    Likelihood                                    Action Required                                        Date of Review                Change note
                                            Objective                                                                        Risk            Risk                                                    Director                      Date
                                                          Inability to respond to a state                                                                Action Plan found at G/Public Health.                                                No new actions planned at the moment
                                                          of emergency such as an                                                                        Infection Control Nurse in post.
                                                          outbreak of Pandemic Flu;                                                                      Increasing capacity for emergency
                                                                                                                                                         planning by 0.5wte.
                                                                                                                                                         Detailed new Pandemic Flu Plan
                                                                                                                                                         being developed.
    PH023/2008       Apr-08         1        Targets                                             5              3               15             12        Business Continuity Plan being                MK          Dec-09          Mar-10
                                                                                                                                                         developed.
                                                                                                                                                         Investment of 5K in Emergency
                                                                                                                                                         support Services
                                                                                                                                                         Immunisation starting in Oct 09


                                                          Inability to further                                                                           Sub-group to be set up as part                                                       Small numbers make it difficult to
                                                          reduce the rate of                                                                             of the Local Implementation                                                          control as the results can fluctuate
                                                          Suicide and                                                                                    Team for Mental Health. Mental                                                       significantly, meaning it is difficult to
                                                          Undetermined injury                                                                            Health Promotion Strategy to be                                                      mitigate - liklihood of current risk has
                                                          Mortality Rate                                                                                 developed to include this area                                                       been raised as reports of an increase
    PH024/2008       May-08         1        Targets                                             3              4               12              9        of work                                       MK          Dec. 09         Mar-10     in the number of suicides has been
                                                                                                                                                                                                                                              received. This is being investigated.




                                                          Failure to fully implement the                                                                 Extra funding has been made
                                             National     NSF for children, young                                                                        available to tackle long waiting list for
    PH027/2008       Jun-08         7        Service      people and maternity                   3              4               12              9        paediatric occupational therapy               MK          Mar-10         ongoing
                                           Frameworks     services
                                                          Failure to deliver the healthy                                                                 SCPHNS has implemented                                                               Current risk increased to 15 from 12 as
                                                          child programme                                                                                escalation plans prioritising targetted                                              although recruitment has taken place long-
                                                                                                                                                         child protection with identified                                                     term sickness levels are high & workload
                                                                                                                                                         families this affecting both universal                                               pressures continue to increase.
                                             National                                                                                                    surveillance and prevention activities
    PH028/2008       Jun-08         7        Service                                             3              5               15             12        -EOI for increasing capacity in the           MK          Mar-10         ongoing
                                           Frameworks                                                                                                    Community Public Health Nursing
                                                                                                                                                         Service to reflect increase in
                                                                                                                                                         workload.


                                                          Failure to increase                                                                            Commissioning care pathway in
                                                          termination of pregnancy                                                                       Bristol amended - need to escalate
                                                          within 9 weeks of gestation                                                                    our commissioning intentions with
    PH002/2009       Jun-09         1        Targets      to 100% of women who                   3              4               12              9        WAHT                                          MK          Mar-10          Mar-10
                                                          present early enough from
                                                          Mar 09
                                                         Failure to safeguard and                                                                        Action Plan in place                                                                 We have increased the consequence to 4 in
                                                         promote the welfare of                                                                                                                                                               light of the current national concerns over
                                           Standards for children and young people                                                                                                                                                            child protection therefore new to the
    PH004/2009       Mar-09         2                                                            4              4               16             12                                                      MK          Mar-10          Mar-10     Corporate Risk Register. Additional staff now
                                           Better Health
                                                                                                                                                                                                                                              in place and reduce likelihood, but challenges
                                                                                                                                                                                                                                              remain. Risk increased from 12 to 16.

                                                          Inability to reduce the                                                                        Discuss with stop smoking team and
                                                          number of women who                                                                            develop an action plan
    PH008/2009       Jun-09         8      Inequalities   continue to smoke in                   3              4               12              9                                                      MK          Dec-09          Mar-10
                                                          pregnancy to agreed level
                                                          Failure to reach target of                                                                     Action plan in place.
                                                          96% of schools achieving                                                                       On track to achieve target
    PH009/2009       Jun-09         12     Partnerships                                          4              3               12              8                                                      MK          Dec-09          Mar-10
                                                          healthy schools standard

                                                          Fail to ensure an identified                                                                   Complex Needs Nurses are now part
                                                          care coordinator for all                                                                       of an integrated service for children
                                                          children receiving long term                                                                   with Complex Needs. This is a key
    PH013/2009       Jun-09         1        Targets      support                                4              3               12              8        part of the integration of services for       MK          Mar-10          Mar-10
                                                                                                                                                         disabled children and will been
                                                                                                                                                         included in the specification for that
                                                                                                                                                         service
                                                          Failure to implement NICE                                                                      EOI has been submitted for BNSSG                                                     We are not implementing this screening and
                                                          guidelines re 1st Trimester                                                                    area                                                                                 will not this year. The costs of implementing
    PH015/2009       Dec-09         8      Inequalities   screening for Down's                   3              5               15             15                                                      MK          Mar-10          Mar-10     next year are substantial, and the likelihood of
                                                          syndrome                                                                                                                                                                            funding is uncertain.
                                                                                                                                                                                                                                              New risk
Quality & Redesign (ex Quality & Governance) Risks


Page 7 of 14                                                                                              D:\Docstoc\Working\pdf\72e2da9b-7509-480a-b12b-e227d3e7a5e7.xls                                                                                                                        ]
                                                                                                                                   NSPCT
                                                                                                                            Corporate Risk Register


                                           Corporate                                                                     Current        Expected                                                  Lead                       Completion
       Ref No    Date of Entry   BAF No                   Risk                           Consequence    Likelihood                                    Action Required                                       Date of Review                Change note
                                           Objective                                                                      Risk            Risk                                                   Director                      Date
                                                          Inability to reduce MRSA                                                                    Community antibiotic prescribing                                                    Band 6 Audit & Surveillance Nurse started
                                                          and other healthcare                                                                        audit.                                                                              Nov 09
                                                          acquired infections in
    QR001/2008      Apr-07         1         Targets      commissioned services               4              3               12              8                                                     JC          Monthly         Mar-10
                                                          resulting in severe patient
                                                          harm
                                                          Inadequate mechanisms for                                                                   Consultations with AD of Strategic                                                  Problems in staffing PALS addressed short
                                                          the involvement of users                                                                    Development to embed consultation                                                   term.
                                                          and the public in changes                                                                   procedures
                                                          and decisions affecting                                                                     Increase pool of lay volunteers as
                                                          commissioned services of                                                                    ambassadors to push Voices for
                                            Patient &     the PCT according to                                                                        Health
    QR009/2008      Apr-07         9         Public       regulatory requirements             3              4               12              9        Active involvement in Wrington Vale          JC          Weekly          Mar-10
                                          Involvement                                                                                                 Practice consultation programme
                                                                                                                                                      Active involvement in Clevedon
                                                                                                                                                      Hospital consultation programme
                                                                                                                                                      Assessment of staffing in PALS area
                                                                                                                                                      being undertaken


                                                        Independent Contractors                                                                       Next dentistry working group meeting
                                                        may not comply with                                                                           in Dec 2009.
                                                        statutory duty of delivery                                                                    Developing clinical governance
                                          Standards for care, resulting in shortage of                                                                dental lead job - description to go to
    QR011/2008      Apr-07         2                                                          4              3               12              9                                                     JC         Quarterly        Mar-10
                                          Better Health patient care.                                                                                 PEC in Dec.
                                                                                                                                                      PEC paper on accreditation of
                                                                                                                                                      practitioners with special interests to
                                                                                                                                                      be presented to PEC in Nov.

                                                          Failure to reach levels of                                                                  Set up cleaning standards monitoring                                                Cleaning Policy agreed at Nov 09 COIC.
                                                          cleanliness to achieve                                                                      group.
                                                          national top 10%                                                                            Ensure NS provider services, NBT,
                                                                                                                                                      UHB and Weston have ongoing
                                          Standards for                                                                                               programme of deep clean activity.
    QR015/2009      Jul-09         2                                                          4              4               16             12                                                     JC          Monthly         Mar-10
                                          Better Health                                                                                               Cleanliness audits to be set up for at
                                                                                                                                                      least quarterly.
                                                                                                                                                      Investigate single contract for
                                                                                                                                                      cleaning GP premises.

                                                          Mechanisms are not in place                                                                 Single Equality Plan being                                                          First meeting of the Corporate Equality Group
                                                          to ensure that commissioned                                                                 implemented over 3 years                                                            rescheduled for January 2010.
                                                          services are not being
                                            Patient &
    QR016/2009      Sep-09         9                      delivered in line with the          3              4               12              9                                                     JC                          Mar-10
                                             Public                                                                                                                                                           Quarterly
                                                          single equality scheme and
                                          Involvement
                                                          current underpinning
                                                          equalities policies &
                                                          procedures
HR & OD Risks
        None
Provider Risks
                                                        Inability to provide                                                                          Consider removal as issue has been
                                                        consistent service to PCT                                                                     re-risk assessed because of staff
                                          Standards for
    PR016/2008      Dec-08         2                    patients either referred              4              3               12              4        sickness.                                    PB           Dec-08         Mar-10
                                          Better Health
                                                        through Safeguarding adults
                                                        or as self neglect.
                                                        The Speech and Language                                                                       Recent discussion needs to be
                                                        service in the Community                                                                      reflected on original RA,
                                          Standards for Team for people with a
    PR017/2009      May-09         2                                                          4              3               12              4                                                     PB          May-10          Mar-10
                                          Better Health Learning Disability currently
                                                        has no qualified Speech and
                                                        Language therapist.
                                                        Admission to safe haven                                                                       Current provision of safe haven beds                                                New risk
                                                        beds                                                                                          under review by commissioning and
    PR029/2009      Oct-09         9       Inequalities                                       3              5               15              2        provider senior managers                     PB           Dec-09         Mar-10


                                                          Consistency in approach,                                                                    Issues to be referred to NSC lead,                                                  New risk
                                                          advice and ongoing support                                                                  incident reporting to hightlight issues,
    PR030/2009      Oct-09         9       Inequalities   in SA issues due to long            4              3               12              4        SA rota to be circulated on a 2/52           PB           Dec-09         Mar-10
                                                          term absence of PCT SA                                                                      basis.
                                                          lead nurse




Page 8 of 14                                                                                           D:\Docstoc\Working\pdf\72e2da9b-7509-480a-b12b-e227d3e7a5e7.xls                                                                                                                    ]
                                                                                                                               NSPCT
                                                                                                                        Corporate Risk Register
                                                                                                                   DELETED RISK RECORD
                                  BAF    Corporate    Risk                                                                                Residual    Action Required                         Responsibi                   Date of
       Ref No     Date of Entry                                                          Consequence      Likelihood      Risk Rate                                                                      Date of Review                          Reason
                                   No    Objective                                                                                          Risk                                                 lity                     Removal
Strategic Development (ex Commissioning Services) Risks including those transferred from other Directorates
                                                      Winter planning to manage                                                                       Ensure WAHT carry through plans to                                             Removal agreed at May 09
                                                      additional demands during                                                                       increase A&E and medical beds                                                  Quality & Governance Meeting
                                                      winter 08/09.                                                                                   capacity; Ensure Community
                                          Service                                                                                                     Services are working at optimal
    SD017/2008       Sep-08        6
                                         Redesign
                                                                                              4                2               8                  8                                               JG         Nov-08        Feb-09
                                                                                                                                                      capacity; Ensure robust continuity
                                                                                                                                                      plans in place across health and
                                                                                                                                                      social care; Ensure thorough
                                                                                                                                                      implementation of Winter Plan;
                                                      Risk of failure to deliver                                                                      Guidelines have been developed for                                             Removal agreed at May 09
                                                      7,500 cases of psychosis                                                                        GPs , has undergone extensive                                                  Quality & Governance Meeting
                                                      which are served by early                                                                       marketing
                                                      intervention teams per year
    SD006/2009       Feb-09        1      Targets                                             2                3               6                  6                                               JG        Monthly        Mar-09
                                                      nationally. This target is set
                                                      at 22 but we are having
                                                      difficulties identifying clients
                                                      with psychosis.
                                                      If the PCT does not                                                                             Commission a psychiatric liaison                                               Removal agreed at May 09
                                                      commission psychiatric                                                                          service for all adults within A&E at                                           Quality & Governance Meeting
                                                      liaison services within A&E                                                                     WAHT.
                                                      at WAHT, this may result in
                                                      increased no. of admissions
                                                      and length of stay. The PCT
                                                      will not achieve the SHA
                                                      Ambition that all people
                                                      receiving NHS care for
    SD008/2009       Feb-09        1      Targets                                             2                3               6                  6                                               JG         Feb-09        Mar-09
                                                      physical conditions to have
                                                      access to a full range of
                                                      psychiatry services by 31
                                                      March 2009 and this will
                                                      also be removing service as
                                                      there is currently a
                                                      psychiatric liaison service
                                                      within A&E at WAHT

                                                      Suicide and undetermined                                                                        As part of the work programme of                                               Removal agreed at May 09
                                                      mortality rate (Tier 2)                                                                         the Local Implementation Team for                                              Quality & Governance Meeting
                                                                                                                                                      Mental Health a sub group will be set
    SD009/2009       Feb-09        1      Targets                                             2                3               6                  6   up to develop a mental health               JG        Monthly        Dec-09
                                                                                                                                                      promotion strategy which will include
                                                                                                                                                      Suicide prevention and reduction.

                                                      Digital Retinopathy                                                                             Recovery plan put in place in                                                  Removal agreed at May 09
                                                      Screening: Q3 data                                                                              conjunction with NHS Bristol.                                                  Quality & Governance Meeting
    SD011/2009       Feb-09        1      Targets     suggests that the nbational             2                3               6                  6   Weekly performance monitoring.              JG        Ongoing       Weekly
                                                      and local targets for DRS
                                                      will not be met by Q4
                                                      Failure to fully implement                                                                      To commission a direct access                                                  Removal agreed at May 09
                                                      and fund NICE technology                                                                        service for DEXA scans for GP                                                  Quality & Governance Meeting
    SD012/2009       Feb-09        1      Targets     appraisal No. 160 "Primary              1                1               1                  1   practices to send relevant patients         JG         Feb-09        Feb-09
                                                      Prevention of Osteoporosis"                                                                     to. Commissioning Group needs to
                                                                                                                                                      agree funding.
                                                    A&E transport: performance                                                                                                                                                       Transferred to Finance as
     SDGWAS          Sep-07        1      Targets   targets for Cat A, B, C not               3                4              12              12                                                  JG         Feb-08       Ongoing    FP004/2009
                                                    being met.
                                                    Risks associated with the                                                                         Strengthen cross directorate analysis                                          Transferred to Finance as
                                                    portfolio of services                                                                             of investment proposals                                                        FP006/2009
                                                    commissioned through the                                                                          Engage fully with Specialised                                                  Directorate Lead updated
                                                    South West Specialised                                                                            Commissioning Team on refining                                                 13/05/09
    SD014/2009       Feb-09        1      Targets                                             2                3               6                  6                                               JG         Feb-09        Mar-10
                                                    Commissioning Group. In                                                                           proposal
                                                    particular, the risks related                                                                     Assess reasons for spend above
                                                    to the proposed level of                                                                          benchmark
                                                    investment.
                                                    Non-Elective Work Transfer                                                                        Working with individual GP practices                                           Project stopped mid02008
                                                    Project. Woodspring GPs                                                                           in a staged approach to win support                                            Removal agreed at August
                                                    may not switch referrals                                                                          for referral change and to give                                                Quality & Governance Meeting
                                        Development
                                                    from UHB to Weston in                                                                             assurance of WAHT's capacity to
    SD016/2008       Sep-08        5     of Weston                                            3                3               9                  9                                               JG         Nov-08        Mar-09
                                                    09/10 resulting in financial                                                                      manage shift. Working with AIM&T
                                          Hospital
                                                    shortfall for WAHT.                                                                               to undestand the impact of transfer
                                                                                                                                                      of activity and magnitude of shift.




Page 9 of 15                                                                                       D:\Docstoc\Working\pdf\72e2da9b-7509-480a-b12b-e227d3e7a5e7.xls                                                                                                  ]
                                                                                                             NSPCT
                                                                                                      Corporate Risk Register
                                                                                                 DELETED RISK RECORD
                                            Inability to meet key targets                                                           Recruit interim manager. Go out to                                   New post holder to commence
                                            in strategic planning                                                                   advert and secure permanent                                          on 1 Sept 09. Interim
                                            including BHSP due to                                                                   member of staff as soon as possible                                  arrangements in place.
                                            vacancy at AD level                                                                     using recruitment agency
                                                                                                                                    Action Plan implemented; AD
                                                                                                                                    recruited but withdrew at late stage.
    SD011/2008   Sep-08   1     Targets                                      3               1               3                  3                                             JG   Monthly     Sep-09
                                                                                                                                    Options being explored by Lead
                                                                                                                                    Director.
                                                                                                                                    UPDATE FEB 09: Take advice re
                                                                                                                                    hard to recruit role from HR Director.
                                                                                                                                    Review JD to ensure it reflects
                                                                                                                                    changes re WCC etc.
                                            Inability to implement                                                                  Action plan developed with partners                                  Directorate Lea d Update
                                            findings of SHA Stroke                                                                  to implement the stroke strategy and                                 09/09/09
                                            Strategy review due to                                                                  recommendations from the SHA
                                            insufficient commissioner                                                               review. Will be overseen by the
                              Standards for
    SD015/2008   Sep-08   2
                              Better Health
                                            resources                        2               2               4                  4   NSSSG and reported on to OPSG             JG    Mar-09     Ongoing
                                                                                                                                    and PEC. This includes resolution of
                                                                                                                                    ensuring WAHT stroke beds meet
                                                                                                                                    Sentinel specialist sta

                                            Current paediatric DSN time                                                             0.6 WTE being recruited to manage                                    updated residual risk rating
                                            is insufficient to properly                                                             risk.                                                                060309
                                            manage all the children with
                                National    diabetes in Nsomerset, due
    SD020/2008   Oct-08   7     Service     to the number of new             1               1               1                  1                                             JG   Dec-08      Apr-09
                              Frameworks    patients diagnosed and the
                                            need to prioritise these over
                                            the existing patients.

                                            ISTC - inadequate                                                                       Implementation of local Project                                      Directorate Lead updated
                                            management response to                                                                  Management arrangements as                                           13/05/09
                                            achieve shift in activity                                                               presented to ET Jan 09
                                            resulting in failure to shift                                                           development of detailed Project Plan
    SD004/2009   Jan-09   1     Targets     sufficient activity equivalent   2               2               4                  4   consistent with AGW Mobilisation          JG   Monthly     Nov-09
                                            to financial commitment and                                                             Plan
                                            to support Second Wave                                                                  links to both PBC Clusters
                                            Programme                                                                               review of current referral patterns
                                                                                                                                    and planned shift of activity
                                            UHBristol are currently not                                                             Monitor UHB action plan. Backlog                                     replaces 022/2008
                                            meeting the 6 week wait                                                                 should be cleared in all specialities
                                            target for some diagnostic                                                              by end Dec 08. (apart from paediatric
    SD024/2009   Mar-09   1     Targets     specialties.                     3               1               3                  3   MRI and neurophysiology)                  JG   Quarterly   Mar-10
                                                                                                                                    Neurophysiology - alternative
                                                                                                                                    capacity being investigated.

                                            Failure to create common                                                                Common assessment documentation                                      Directorate Lea d Update
                                National    assessment process                                                                      and processes being developed as                                     09/09/09
    SD021/2007   Apr-07   7     Service                                      2               2               4                  4   part of the POPP community team           JG    Mar-09     Mar-10
                              Frameworks                                                                                            integration and establishment of a
                                                                                                                                    SPA.
                                            Decision to implement NICE                                                              Liaise with Directors on                                             Directorate Lea d Update
                                            Tags sooner than 90 days of                                                             implementation date, highlight risk.                                 09/09/09
                                            publication. Potential                                                                  Processes to be put in place via
    SD028/2009   Apr-09   4     Finance     financial risk to PCT if         1               5               5                  5   BNSSG NICE College with Acute             JG   Monthly     Ongoing
                                            implemented sooner.                                                                     Trusts to pre-empt possible Tags
                                                                                                                                    that will require earlier
                                                                                                                                    implementation.
                                            Survellance Endoscopies at                                                              NBT action plan, increased capacity                                  Directorate Lea d Update
                                            NBT - backlog of patients                                                               to clear backlog, validation of waiting                              09/09/09 - transferred to Finance
    SD034/2009   Apr-09   1     Targets                                      1               1               1                  1                                             JG   Monthly     Jun-09
                                            overdue                                                                                 list.                                                                - agreed at August G&R
                                                                                                                                                                                                         Committee
                                            That Community                                                                          Support to be given following                                        Directorate Lea d Update
                                            Pharmacists do not comply                                                               community Pharmacy Audits. Audit                                     09/09/09
                              Standards for
    SD036/2009   Apr-09   2
                              Better Health
                                            with Enhanced Services and       1               1               1                  1   09/10 in Autumn/ by December to           JG    Jan-10     Mar-10
                                            / or the advanced service.                                                              ensure risk is minimal through advice
                                                                                                                                    and action points
                                            Community Pharmacy does                                                                 Follow up on issues arising from CP                                  Directorate Lea d Update
                              Standards for
    SD037/2009   Apr-09   2
                              Better Health
                                            not comply with essential        1               1               1                  1   audits                                    JG    Jan-10     Mar-10    09/09/09
                                            services
                                            Failure to fully implement                                                              To commission a direct access                                        Directorate Lea d Update
                                            and fund NICE technology                                                                service for DEXA scans for GP                                        09/09/09
                                            appraisal No. 160 "Primary                                                              practices to send relevant patients
    SD038/2009   Apr-09   1      Targets                                     1               1               1                  1                                             JG    Jun-09     Mar-10
                                            Prevention of Osteoporosis"                                                             to. Commissioning Group needs to
                                                                                                                                    agree funding. Work started in 08/09
                                                                                                                                    but not yet completed.


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                                                                                                                        NSPCT
                                                                                                                 Corporate Risk Register
                                                                                                            DELETED RISK RECORD
                                                       Inability to Implement the                                                              Continuation of Sunsmart Campaign                                Transferred to Finance agreed
                                                       Cancer Reform Strategy                                                                  Childhood obesity Action Plan                                    by August Gov&Risk Committee
                                                                                                                                               PCT Alcohol Strategy
                                                                                                                                               Expansion of the Sunsmart
                                       Standards for
    SD013/2009       Feb-09       2
                                       Better Health
                                                                                        2               3               6                  6   campaign by the DoH                     JG   Aug-09    Dec-12
                                                                                                                                               Public awareness campaign by the
                                                                                                                                               DoH
                                                                                                                                               New National Targets for Cancer

                                                    Diagnostic capacity at                                                                     Additional evening and weekend                                   Transferred to Finance - agreed
                                                    Weston District General                                                                    sessions have been implemented.                                  by August G&R Committee
                                                    Hospital will not be able to                                                               The concern is whether a sustained
                                       Development
                                                    meet the demand for its                                                                    demand, particularly for all scope
    SD005/2008       May-07       5     of Weston                                       2               3               6                  6                                           JG   Oct-09    Ongoing
                                                    services as the Trust works                                                                tests, can be managed using
                                         Hospital
                                                    towards a 4 week wait by                                                                   additional sessions. New MRI to
                                                    the end of autumn 2009 to                                                                  come online in autumn 2009
                                                    deliver 13 weeks.
                                                    Portishead primary care                                                                    Use project management discipline                                Removal previously agreed by
                                         Service
    SD015/2007       Apr-07       6
                                        Redesign
                                                    resource centre not running         3               3               9                  9   including risk assessment to identify   JG   Monthly   May-09    Gov&Risk committee.
                                                    according to timescales                                                                    action needed
                                                    Some patients whose needs                                                                  NHSNS to collate info from all PCTs                              Transferred to Finance from
                                                    are high cost. Lack of                                                                     in SW re which providers are being                               Strategic Planning (SD021/2009)
                                                    suitable providers,                                                                        used to deliver these placements.                                Retransferred back at request of
    SD021/2009       Mar-09       4      Finance    complexity of needs and size        3               3               9                  9   Negotiations in collaboration with      MH   Oct-09    Mar-10    ET (15/7/09)
                                                    of contracts affords                                                                       other PCTs to achieve better value
                                                    providers negotiating                                                                      for money
                                                    strength
                                                    Reprocurement of home                                                                      HOS part of procurement team                                     Contract awarded. Performance
                                                    oxygen service (HOS)                                                                       working towards smooth transistion                               Management arrangements in
                                                    contract, transfer of contract                                                             in early 09. Communications to                                   place. Residual risk reduced to 2
                                                    to new provider. Transfer of                                                               clinicians, patients and regular                                 - 30/09/09.
                                                    service may reduce quality                                                                 briefing with PALs.
                                          Patient
    SD006/2008       Jun-08       3
                                       Satisfaction
                                                    to pts, new supplier not            1               2               2                  2                                           JG   Oct-09    May-10
                                                    familiar with area. Pts
                                                    anxious of change. Impact
                                                    on HOS lead and PALs
                                                    answering queries.

                                                   Inability to establish the                                                                  Partnership Board set up and has                                 All ADs in post. Sharing Pan
                                                   capacity to work with the                                                                   met twice. Workstreams agreed and                                PCT workload. Residual risk
                                       Development
                                                   Bristol Health Services Plan                                                                work programme being managed                                     reduced from 6 to 4 - 30/09/09
    SD009/2007       Apr-07       5     of Weston                                       2               2               4                  4                                           JG   Oct-09    Ongoing
                                                   and ensure future of Weston                                                                 and on schedule but is ongoing.                                  subject to reassessment
                                         Hospital
                                                   is considered                                                                               Workshops held for 5 pathways.

Finance & Performance Risks including those transferred from other Directorates
                                                       Inability to complete agreed                                                            Regular performance monitoring with                              Transferred to Finance from
                                                       recovery plan                                                                           SHA has been set up and is an                                    Strategic Planning
                                                                                                                                               ongoing process. Weston Futures                                  (SP011/2007), merged with
                                       Development
                                                                                                                                               Board has met in November and                                    FP002/2009
    FP005/2008       Apr-08       5     of Weston                                       3               3               9                  9                                           MH   Feb-08    Ongoing
                                                                                                                                               good progress has been made in key
                                         Hospital
                                                                                                                                               areas. Programme of work will
                                                                                                                                               continue and structure will be agreed
                                                                                                                                               by Chairs and CEO's.
                                                       Long CHC assessment                                                                     Continued close monitoring of                                    Transferred to Finance from
                                                       waiting list due to low                                                                 waiting list figures                                             Strategic Planning (SP020/2009)
                                                       threshold set within CHC                                                                                                                                 Retransferred to Strategic
                                                       Nat. Framework and limited                                                                                                                               Planning (SP018/2009)
                                                       Nurse Assessor resources.
                                                       Uncertainty for patients and
                                                       carers, exposes PCT to
                                                       financial risk, though patient
    FP007/2009       Mar-09       4      Finance       care not affected. Also, LA      3               3               9                  9                                           MH   Oct-09    Dec-09
                                                       may be funding patients who
                                                       are PCT’s responsibility.
                                                       Difficult to predict number of
                                                       people who may request a
                                                       CHC assessment, so large
                                                       numbers on waiting list
                                                       create a financial risk.




Page 11 of 15                                                                               D:\Docstoc\Working\pdf\72e2da9b-7509-480a-b12b-e227d3e7a5e7.xls                                                                                         ]
                                                                                                                        NSPCT
                                                                                                                 Corporate Risk Register
                                                                                                            DELETED RISK RECORD
                                                        Some patients whose needs                                                              NHSNS to collate info from all PCTs                            Transferred to Finance from
                                                        are high cost. Lack of                                                                 in SW re which providers are being                             Strategic Planning (SP021/2009)
                                                        suitable providers,                                                                    used to deliver these placements.                              Retransferred back at request of
    FP008/2009       Mar-09        4      Finance       complexity of needs and size    3               3               9                  9   Negotiations in collaboration with      MH   Oct-09   Mar-10   ET (15/7/09)
                                                        of contracts affords                                                                   other PCTs to achieve better value
                                                        providers negotiating                                                                  for money
                                                        strength
Public Health Risks including those transferred from other Directorates
                                                      Failure to support LAA                                                                   Assessing high risk areas
      002/2008        Apr-07       8     Inequalities                                   3               2               6                  6                                           MK   Apr-08   Mar-09
                                                      targets
                                                      Failure to ensure partnership                                                            Development of shared public health
      006/2008        Apr-07       13   Partnerships arrangements to deliver PSA        3               2               6                  6   work programme                          MK   Apr-08   Mar-09
                                                      targets
                                          Patient &   Inability to improve the                                                                 A range of strategies developed in
      018/2008       Mar-08        9       Public     health of adults and children     3               2               6                  6   partnership with the local authority    MK   Jun-08   Sep-08
                                        Involvement
                                                      Apart from Clevedon                                                                      Facilities manager Vicki Lovis has
                                                      hospital; no Major PCT                                                                   asked Mitie for quotes to supply fit
                                                      building has backup power                                                                and maintain stby generators
                                                      available in the event of a                                                              permantly or on an as required
                                                      power outage. For a short                                                                contract 26-01-09
                                                      term outage of an hour or so
                                                      this may be an acceptable
                                                      risk; however for any outage
                                                      for longer than an hour the
                                        Standards for PCT HQ, East End Court,
      001/2009       Jan-09        2
                                        Better Health Worle Health Centre &
                                                                                        5               4              20              20                                              MK
                                                      Griffin House, would not be
                                                      useable and service delivery
                                                      would be severely affected.
                                                      If an outage occured due to
                                                      a Major Incident (severe
                                                      Weather, Flooding etc) then
                                                      the PCT would have no
                                                      useable ECC or backup
                                                      available.

                                                        Absence of permanent                                                                   Paeditrician has been recruited but
                                            #N/A        Designated Doctor for Child     1               3               3                  3   formal SLA still to be signed           MK   Mar-09
                                                        Protection
                                                        Produce and monitor a                                                                  Agreement of service specification
                                                        robust service level                                                                   and formal sign off
                                                        agreement for
                                                        commissioning an integrated
                                            #N/A                                        2               3               6                  6                                           MK   Dec-08   Oct-08
                                                        Public Health Nursing
                                                        Service (health
                                                        visiting/school nursing
                                                        service)
                                                        Number of specialist                                                                   Funding required to recruit more
                                                        CAMHS WTE                                                                              CAMHS specialist to achieve NSF
                                        Standards for
     008a/2008       Jun-08        2
                                        Better Health
                                                                                        2               5              10              10      benchmark - LDP proposal to be          MK   Jul-09   Apr-09
                                                                                                                                               prepared for next operational plan
                                                                                                                                               not successful
                                                        Under 75 Cardio vascular                                                               Review data, Implement targeted
                                                        disease mortality rate                                                                 CVD risk assessment project,
                                          National
                                                        (Failure to achieve target)                                                            monitor GP activity on CHD through
    PH019/2008       Mar-08        7      Service                                       3               3               9                  9                                           MK   Sep-09   Mar-10
                                                                                                                                               QMAS.
                                        Frameworks
                                                                                                                                               Public Health Vascular screening
                                                                                                                                               programme in 2009
                                                        Inability to ensure reduction                                                          LAA and Health Inequalities Action
                                                        in Health inequalities                                                                 Plan (found at G/Commissioning &
    PH001/2008        Apr-07       1      Targets                                       3               3               9                  9                                           MK   Oct-10   Mar-10
                                                        including smoking cessation                                                            Service Development & G:/Public
                                                        see below                                                                              Health)
                                                        Failure to increase smoking                                                            Action plan found at G:/Public Health
                                          Patient &
                                                        cessation                                                                              - Number of staff resignations and
    PH004/2008        Apr-07       9       Public                                       3               3               9                  9                                           MK   Oct-10   Mar-10
                                                                                                                                               sickness. Recruitment plan in place
                                        Involvement




Page 12 of 15                                                                               D:\Docstoc\Working\pdf\72e2da9b-7509-480a-b12b-e227d3e7a5e7.xls                                                                                      ]
                                                                                                                        NSPCT
                                                                                                                 Corporate Risk Register
                                                                                                            DELETED RISK RECORD
                                                      Inability to recruit to current                                                          Proposal from WAHT to
                                                      LD Psychiatry vacancy                                                                    commissioing group at end of May
                                                                                                                                               unsuccessful - Risk assesment on
                                                                                                                                               children and young people on waiting
    PH001/2009       Mar-09       1      Targets                                        4               3              12              12      list is being undertaken -                MK   May-09     Sep-10
                                                                                                                                               Commissioner contacting
                                                                                                                                               neighbouring PCTs to explore
                                                                                                                                               options for comissioning this service

                                                      Insufficient capacity in                                                                 Implement the Alcohol Strategy using
                                                      alcohol treatment services to                                                            funding for alcohol services identified
    PH003/2009       Mar-09       1      Targets                                        4               4              16              16                                                MK   Oct-10     Mar-10
                                                      meet need in the                                                                         in the operational plan
                                                      community.
                                      Standards for   Ability to manage a                                                                      Review of current plans in light of
    PH005/2009      May-09        2                                                     4               2               8                  8                                             MK   Sep-09
                                      Better Health   pandemic                                                                                 experience
                                                      Business continuity may be                                                               Plan in place for next level of
                                      Standards for
    PH007/2009      May-08        2
                                      Better Health
                                                      adversely affected by the         4               3              12              12      operation                                 MK   Ongoing    Mar-10
                                                      incidence of swine flu
Quality & Redesign (ex Quality & Governance) Risks
                                                      Non compliance with                                                                      Assurance programme in place.                                      Transferred to Strategic Planning
                                                      Standards for Better Health                                                              Deadline for evidence templates                                    following realignment.
                                                      Domains                                                                                  completion 9th March.
                                                                                                                                               Identifying possible risk areas
                                      Standards for                                                                                            against compliance.
    QR002/2008       Apr-07       2
                                      Better Health
                                                                                        4               2               8                  8                                             JC   Monthly    Mar-10
                                                                                                                                               Report to the Board on 29/4/9 in
                                                                                                                                               readiness for 1st May declaration
                                                                                                                                               intended to declare full compliance
                                                                                                                                               subject to confirmation of other acute
                                                                                                                                               provider.
                                                    Business continuity may be                                                                 Plan in place for next level of                                    Transferred to Public Health
                                      Standards for
    QR001/2009      May-08        2
                                      Better Health
                                                    adversely affected by the           3               3               9                  9   operation                                 JC   Ongoing    Mar-10   following realignment.
                                                    incidence of swine flu
                                        Patient &   New ways of working for                                                                    Included in LDP/PBC Gateway                                        Completed
    QR010/2008       Apr-07       9      Public     Involving People in PBC is          2               3               6                  6   documentation.                            JC   Monthly    Mar-10
                                      Involvement not developed
                                                    Lay input into service may                                                                 Involving People Strategy being                                    Combined with QR009/2008
                                                    not be adequate as people                                                                  developed.
                                                    may drop out due to new                                                                    12 lay people appointed.
                                                    issues around non-payment                                                                  Matrix of opportunities allocated.
                                                                                                                                               Strategy in place.
                                                                                                                                               Database of public involvement
                                         Patient &
                                                                                                                                               established plus specific groups e.g.
    QR007/2008       Apr-07       9       Public                                        2               2               4                  4                                             JC   Monthly    Mar-10
                                                                                                                                               The Rural Communities Group.
                                       Involvement
                                                                                                                                               Further development of team taking
                                                                                                                                               place.
                                                                                                                                               Involving People Team working well.
                                                                                                                                               To be reassessed in a few months
                                                                                                                                               time

                                                    Failure of providers to
                                      Standards for
    QR004/2008       Apr-07       2
                                      Better Health
                                                    deliver quality targets in the      2               2               4                  4                                             JC   Monthly    Sep-09
                                                    SLA
Provider Risks
                                                    Podiatry and other clinics                                                                                                                                    Marina healthcentre
                                      Standards for are limited across NSPCT                                                                                                                                      development includes Pod
      006/2007     1st Oct 07     2
                                      Better Health due to lack of appropriate
                                                                                        4               4              16                  9                                             PB   Oct 2008
                                                                                                                                                                                                                  provision, remove from list
                                                    accommodation
                                                    Lack of SLAs for exisiting                                                                                                                                    Action taken, remove from
      007/2007     1st Oct 07     4      Finance    Podiatric services allows for       4               5              20              12                                                PB     nil               register
                                                    double billing.
                                                    Unsuitable accommodation                                                                                                                                      Move to Griffin end of Oct
                                      Standards for is affecting the delivery of                                                                                                                                  pending lease approval. Once
      008/2007     1st Oct 07     2
                                      Better Health some services within
                                                                                        4               5              20                  6                                             PB   Oct 2008
                                                                                                                                                                                                                  approved, remove from list
                                                    provider
                                                    Lack of Inpatient OT service                                                                                                                                  OT waiting times are now at
                                                    at weston Hospice increases                                                                                                                                   manageable level, remove from
      009/2007     1st Oct 07     1      Targets                                        4               5              20                  6                                             PB   Oct 2008
                                                    referrals to PC OT team                                                                                                                                       list

                                      Standards for Possibility of incorrect drug                                                                                                                                 Remove from register
      010/2007     1st Oct 07     2                                                     4               5              20                  3                                             PB     N/A
                                      Better Health administration
                                                    potential for patients                                                                                                                                        policy written, review of NPSA
                                      Standards for receiving wrong blood                                                                                                                                         regs required, remove from list
      011/2007       Nov-07       2
                                      Better Health causing harm. Non
                                                                                        4               3              12                  2                                             PB   Feb-09
                                                    compliance with legislation



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                                                                                                               NSPCT
                                                                                                        Corporate Risk Register
                                                                                                   DELETED RISK RECORD
                               Standards for Lack of PCT COSHH policy                                                                                                                          policy written, COIC to reviewed,
      012/2007   Dec-07   2                                                    4               4              16                  1                                            PB   Oct 2008
                               Better Health                                                                                                                                                   remove from list
                                             Lack of NICE review                                                                                                                               GQRG to act as Provider NICE
                               Standards for process                                                                                                                                           review group and link with
      013/2008   Oct-08   2
                               Better Health
                                                                               4               2               8                  1                                            PB   Nov-08
                                                                                                                                                                                               Commissioning group, remove
                                                                                                                                                                                               from list
                                             There is the potential for                                                               Skill mix review, update training for                    All risks below have been
                                             patient care is compromised                                                              Minor Injury Unit staff & direct                         incorrectly placed on the CRR.
                               Standards for because 1 nurse is looking                                                               communication with the police                            They previously have shown
    PS014/2007   Oct-07   2                                                    4               3              12                  4                                            PB   Oct-09
                               Better Health after 3 beds spread across                                                               station. Included in Clevedon                            their primary risk grade, not the
                                             two rooms in the Minor Injury                                                            Community Hospital Outline                               current risk grade as required.
                                             Unit.                                                                                    Business Case
                                             Lack of formal signup                                                                    Original risk assessment requires
                               Standards for
    PS015/2007   Nov-07   2
                               Better Health
                                             agreement breaches data           4               5              20                  6   review with line manager and             PB   Oct-09
                                             protection requirements                                                                  originator
                                             Inability to provide                                                                     RA review required in Oct 09
                                             consistent service to PCT
                               Standards for
    PS016/2008   Dec-08   2
                               Better Health
                                             patients either referred          4               5              20              12                                               PB   Oct-09
                                             through Safeguarding adults
                                             or as self neglect.
                                             Failure to respect equality                                                              Attempting to arrange a meeting in
                                             and diversity of indviduals by                                                           Oct 09. Ongoing risk that PCT
                                             promoting personal religious                                                             receives further reports of patient
                                             beliefs without consent.                                                                 concerns.
    PS019/2009   Jun-09   13   Partnerships Adverse media attention and        4               5              20                  9                                            PB   Oct-09
                                             damage to organisational
                                             reputation. Adverse impact
                                             of media interest on staff.

                                              The Specialist Community                                                                Locality Leader now in post and
                                              Public Health Nursing                                                                   reviewing mitigation plan regularly
                                              Service is currently under
                                              stress due to chronic
                                              difficulties in recruiting to
    PS020/2009   Jun-09   1       Targets                                      5               4              20                  6                                            PB   Oct-09
                                              vacancies, long term staff
                                              sickness and maternity
                                              leave which may result in
                                              failure to achieve contractual
                                              targets.
                                              The potential for the                                                                   Discussed at PMT. Full action plan
                                              Endoscopy service to be                                                                 available. Agreement to purchase a
    PS021/2009   Jul-09   1       Targets     suspended as not compliant       4               5              20                  6   new sterliser. Review now due Oct        PB   Oct-09
                                              with Health Techinical                                                                  09
                                              Memorandum 2030
                                              The potential that Financial                                                            CRES planning meeting organised
                                              Balance will not be achieved                                                            with all Service Heads during
                                              due to Cash Releasing                                                                   September, feedback required for
    PS022/2009   Jul-09   4      Finance                                       5               4              20                  9                                            PB   Oct-09
                                              Efficiency Savings not being                                                            Oct
                                              identified and actioned

                                             Unable to provide service to                                                             Recruitment process underway, no
                                             Dysphasic Cerbrovascular                                                                 permanent appointment confirmed.
                               Standards for Accident patients who have                                                               Agency support remains in place.
    PS023/2009   Jul-09   2
                               Better Health been repatriated to
                                                                               4               4              16                  6                                            PB   Oct-09
                                                                                                                                      Risk to remain at 6
                                             Clevedon Community
                                             Hospital
                                             Using Mobile hoist outdoors                                                              Recommendations require further
    PS024/2009   Jul-09   1       Targets    to hoist client into and out of   3               4              12                  6   discussion                               PB   Oct-09
                                             vehicle
                                             Manual handling of patient                                                               Recommendations not agreed,
                               Standards for                                                                                          generic risk assessment on Manual
    PS025/2009   Jul-09   2                                                    4               3               12             12                                               PB   Oct-09
                               Better Health                                                                                          Handling to be written and managed

                                              Not able to conduct 'back                                                               IT dept to solve problem via BT and
                                              office' printing affecting                                                              Fujisu. Further work to mitigate risk
    PS026/2009   Sep-09   1       Targets                                      5               4               20             15                                               PB   Oct-09
                                              patient appoinment letters                                                              required. Manual inputting will reduce
                                                                                                                                      risk further




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