06_01 RR

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					Corporate Risk Register (February 2006)




                                                                                                                                                 Residual
                                                                                                                                                     Risk
Risk Area   Risk Description             Existing Controls                    Score   Cost     Lead          Action Required                                Risk Status Progress                     Date
                                                                                      (000)                                                                                                          Complete



Finance     The trust has a long         Extensive monthly internal and     HIGH              0 DF           To identify a medium term        High          Active     Trust currently working to
            standing underlying          external budgetary monitoring and                                   service plan with the associated                          financial plan
            deficit that will increase   cash controls are in place which                                    financial changes to ensure that
            without corrective action    have been endorsed by an external                                   the trust can apply to be a
            and a cumulative deficit     review. The trust has been subject                                  foundation hospital by 2007/08.
            of around 11 million         to a recovery board process,                                        The plan will need to combine
            depending on the             continual HA scrutiny and                                           additional recurrent income,
            2004/05 outturn position     monitored action plans                                              short term financial support and
                                                                                                             expenditure reduction measures



            Agenda for change and        Extensive monthly internal and      HIGH             0 DF           Continue to follow recovery plan. High         Active     Trust currently working to
            PbR pressure on the          external budgetary monitoring . The                                 Need to further engage                                    financial plan
            organisation threaten        trust has been subject to a HA                                      clinicians in income and activity
            ability to meet financial    scrutiny and monitored action plans                                 monitoring
            targets


            Failure to achieve break Existing controls include cash           HIGH            0 DF           Increase quality of income          High       Active
            even and cash            controls. SFI's and SO's, recovery                                      reporting and relationship to
            management targets       plan and monthly report. Finance                                        activity. Improve directors
                                     monitoring group and budgetary                                          understanding and validity of
                                     allocation                                                              activity and financial relationship


            Failure to develop an        Activity and financial monitoring,   HIGH            0 DF           Budgetary control system          High         Active     Tariff information expected
            understanding of costs       sound financial systems, agreed                                     requires 06_07 tariff information                         this month (Feb)
            in relation to revenue       activity plans
            streams




                                                                                                         H1
                                                                                              Risk Register February 06
                                                                                                                                               Residual
                                                                                                                                                   Risk
Risk Area   Risk Description          Existing Controls                      Score   Cost     Lead          Action Required                               Risk Status Progress                       Date
                                                                                     (000)                                                                                                           Complete



Capital     Lack of fire               Current fire doors, fire alarms and            50,000 DWO            The trust has agreed a budget      Mod        Active     As the project progresses
            Certification. Risk of     evacuations procedures                                               for the scheme and financial                             new demands may be
            loss arising from a fire                                                                        flexibilities will be used between                       uncovered, delays may be
            incident. Fire authority                                                                        years to maintain progress. The                          incurred, and operational
            reports on the limitations                                                                      project management process                               pressures may arise due to
            of the building controls.                                                                       needs to ensure that funds are                           reduced access to facilities.
            Lack of Financial                                                                               protected for the agreed outputs                         The trust has highlighted the
            resources available to                                                                          from the scheme and variations                           gap between required
            complete the fire                                                                               approved by the project board.                           funding during the early
            scheme. The particular                                                                                                                                   years and that available.
            risk related features are
            the lengthy,
            interdependent nature of
            the scheme, the
            shortage of HA capital
            during the first two years
            of the programme which
            may delay progress,
            and the fact that the
            funding of the scheme
            has required approval of
            a very tight set of
            budgetary assumptions.




Quality   Inadequate denominator Current data capture                        HIGH            0 DOSD         Trust methodology for capturing Mod           Active
Assurance figures for surveillance                                                                          data should be improved.
          Need accurate KHO3                                                                                Inadequate denominator figures
          figure for trust plus bed                                                                         for surveillance
          day numbers per
          specialty for surveillance
          purposes and winning
          ways, both in house and
          nationally as results are
          taken as indicators for
          star rating.




                                                                                                        H2
                                                                                             Risk Register February 06
                                                                                                                                             Residual
                                                                                                                                                 Risk
Risk Area   Risk Description        Existing Controls                     Score   Cost      Lead          Action Required                               Risk Status Progress                       Date
                                                                                  (000)                                                                                                            Complete



            CPA                      Microbiology laboratory has          HIGH            68 GM           Ensure health and safety         Low          Accepted   Microbiology lab recently         1/25/2005
                                     provisional accreditation.                                           arrangement are sufficient,                              assessed (25/1/05) 1 critical
                                     Microbiology laboratory needs full                                                                                            non compliance noted,
                                     accreditation (CPA).                                                                                                          however easily resolved.
                                                                                                                                                                   Conditional approval
                                                                                                                                                                   granted pending compliance
                                                                                                                                                                   to failed standard

            Several standards        Current performance indicators,      HIGH            0 DOSD          Standard leads create robust     Low          Active     Actions plans created and
            assessed as insufficient external assessments                                                 action plans to ensure                                   submitted
            assurance for better                                                                          compliance by april 2006
            health standard core
            criteria

Infection   Incomplete               Current staffing levels - 1 WTE      HIGH        200 DOS             Effective arrangements for         Low        Resolved   Microbiologists recruited. Ed Septmber
control     arrangements for         microbiologist/infection control                                     infection control within the trust                       James with overall            2005
            infection control        nurse team                                                           are not complete - business plan                         responsibility for infection
                                                                                                          submitted 2000 not fully                                 control.
                                                                                                          resourced. Need more infection
                                                                                                          control doctor sessions (extra 9
                                                                                                          sessions) to raise to RCPath
                                                                                                          recommended levels. Additional
                                                                                                          sessions are required in both
                                                                                                          microbiology and virology. The
                                                                                                          current number of sessions does
                                                                                                          not reflect the size nor the
                                                                                                          complexity of the patients we
                                                                                                          serve. Infection control should
                                                                                                          be considered as part of all
                                                                                                          service development (including
                                                                                                          the upcoming increase in renal
                                                                                                          patients).




                                                                                                      H3
                                                                                           Risk Register February 06
                                                                                                                                                   Residual
                                                                                                                                                       Risk
Risk Area   Risk Description             Existing Controls                     Score   Cost      Lead          Action Required                                Risk Status Progress                       Date
                                                                                       (000)                                                                                                             Complete



            Lack of formalised           Est. 2 ICD sessions plus 0.5 WTE      HIGH            30 DOS          Need service level agreements Low              Resolved   Arrangements satisfactory       Septmber
            arrangements for             ICN.                                                                  for infection control at sites other                      for RNTNE and Queen             2005
            Infection control at                                                                               than RFH, QM and RNTNE.                                   Mary's. Business case
            satellite units                                                                                    The same level of care should                             created for staff for
                                                                                                               be provided to trust patients at                          Edgware/Barnet/North
                                                                                                               satellite units as on the main                            Middlesex
                                                                                                               hospital sites. This includes
                                                                                                               ensuring private satellite units
                                                                                                               have suitable arrangements in
                                                                                                               place.

            Coordination of activities Current informal and ad hoc             HIGH            0 CEO           Need better coordination of        Low         Accepted   Director of infection control     10/1/2004
            - infection control        reports. Infection control annual                                       activities and communication                              appointed (Carole Holroyd).
                                       report annual report                                                    between trust board, clinical                             Risk management
                                                                                                               governance committee, risk                                arrangements restructured
                                                                                                               management committees and                                 to facilitate better
                                                                                                               the infection control committee.                          communication. Consultant
                                                                                                                                                                         microbiologist is a member
                                                                                                                                                                         of risk management
                                                                                                                                                                         committee and provide
                                                                                                                                                                         regular reports. Risk
                                                                                                                                                                         management committee
                                                                                                                                                                         feeds into the governance
                                                                                                                                                                         committee. Urgent issues
                                                                                                                                                                         can be raised at the board
                                                                                                                                                                         via the Nurse Director




Building/   Exhaust fumes do not         Generator exhaust flues               HIGH        300 DWO             Flues to be replaced               Low         Active     Risk assessment
Plant       meet requirements                                                                                                                                            commissioned to determine
                                                                                                                                                                         condition/action

            RNTNE Electrical             Evaluation of current load. Control   HIGH        200 DWO             Main electrical switchgear to be   Low         Active     Procurement now
            distribution insufficient,   over equipment used                                                   replaced                                                  proceeding.
            switchgear past
            recommended age




                                                                                                           H4
                                                                                                Risk Register February 06
                                                                                                                                                Residual
                                                                                                                                                    Risk
Risk Area   Risk Description            Existing Controls                   Score   Cost     Lead          Action Required                                 Risk Status Progress                      Date
                                                                                    (000)                                                                                                            Complete



            Replacement of              Contingency plans, new              HIGH        150 DWO            Major incident plan to be       Mod             Resolved   Emergency planning                  Apr-05
            switchgear to main          independent electrical feed to                                     implemented during planned                                 meetings held. Essential
            tower riser resulting in    ITU, non essential power                                           works on essential power supply                            services/equipment
            permanent loss of           supply                                                             down time                                                  identified. Contingency
            essential power                                                                                                                                           plans created.
                                                                                                                                                                      Redirected/independent
                                                                                                                                                                      power source created
            Asbestos identified         Asbestos surveys. Current estates   HIGH            7 DWO          phased replacement programme Low                Active     currently removed as part of
            within the trust            protocols                                                                                                                     planned maintenance or
                                                                                                                                                                      when identified after
                                                                                                                                                                      unplanned maintenance.
                                                                                                                                                                      Mainly low grade/low risk
                                                                                                                                                                      asbestos. Current phase is
                                                                                                                                                                      the removal in immunilogy

            Lack of risk             Works design planning team, user       HIGH            0 DWO          Ensure risk                         Low         Active     Risk management
            management               involvement in design                                                 management/infection                                       representative to join
            involvement in new build                                                                       control/security consulted on all                          projects department design
            design/refurbishment                                                                           new builds. Ensure key staff                               team.
            project. Lack of                                                                               have access to up to date
            knowledge of recent                                                                            design legislation and NHS
            HTM/HBN                                                                                        estates guidance

            Lack of planned             Prioritised workplanm               HIGH             DWO           Ensure urgent work is reflected     High        Active     Works department currently
            preventative                                                                                   in capital bid                                             monitoring and capital bids
            maintentance and                                                                                                                                          submitted
            problems to resolve
            maintaince issues not
            lonked to fire works

Pathology   System failures highlight   Local data backup; server to server HIGH        156 PATHO          Replace or update current           Low         Active     We have now agreed with
            susceptibility of the       backup; server differential back-up;                               software                                                   Cysmed to upgrade the
            database architecture,      full server backup.                                                                                                           system free of charge. A
            resulting in potential      R1                                                                                                                            business case to support
            critical data loss                                                                                                                                        the system out of hours will
            Pathology IT system                                                                                                                                       go to the FMG next month



            Blood transfusion                                               HIGH        120 PATHO                                              Low         Active     Funds now made available
            automation                                                                                                                                                for purchase of upgraded
                                                                                                                                                                      equipment.




                                                                                                       H5
                                                                                            Risk Register February 06
                                                                                                                                              Residual
                                                                                                                                                  Risk
Risk Area   Risk Description          Existing Controls                     Score   Cost     Lead          Action Required                               Risk Status Progress                       Date
                                                                                    (000)                                                                                                           Complete




            Failure to obtain CPA     Trust – decreased income               High              PATHO       Create a register of non-       Mod Active               The trust has limited
            accreditation. DOH        generation clinical trial work will                                  compliances together with an                             discretion to influence the
            requires all labs to be   not be able to be undertaken                                         action plan to determine                                 cost of the pay award and
            registered with CPA.      and funding will be lost                                             what needs to be done.                                   the residual issue related to
                                                                                                                                                                    ensuring that the necessary
            Failure will result in                                                                         Identify highest priorities for
                                                                                                                                                                    funding is collected and
            removal from DOH                                                                               capital funding and those                                protected. The trust has
            list. Could not                                                                                that can be rectified within                             completed a costing model
            support specialist                                                                             each specialty or Divisional                             indicating the estimated
            testing under                                                                                  budget. Review and update                                impact of the pay award
            pathology                                                                                      action plan.
            modernisation.


Clinical    Ability to meet working   Junior doctor hour monitoring.        HIGH            5 DF           Working time directive. Reduce Low            Active     New deal /partnership in
            time directive            Restructure of services to                                           junior doctors' working hours to                         care group. Hours are being
                                      provide night teams                                                  48.                                                      regularly monitored, clinical
                                                                                                                                                                    services have been
                                                                                                                                                                    restructured to provide
                                                                                                                                                                    clinical support teams and
                                                                                                                                                                    night teams

            Staff non complaince to Audit programmes, incident              HIGH             MD/ND         Ensure all staff attend induction, Mod        Active
            trust polices and       reporting, communication of                                            enusre audit results are fed back
            procedures              polcies, freenet                                                       and recommendations implented
                                                                                                           and monitored

            Pressure to meet          Incident reporting, risk       HIGH                   0 KF/MD/ND     Ensure risks are adequately      High         Active
            extenal targets (e.g 4    assessments, consultation with                                       raised with the board and action
            hour waits)               clinical staff. Performance                                          plans implemented
            compromises clinical      monitoring
            care
FOI         Non compliance to staff   IT policies, records management       HIGH            0 DOSD         Ensure all staff understand and   Mod         Active
            re FOI act                policies                                                             are aware of FOI act, their
                                                                                                           requirements re data storage
                                                                                                           and are aware of correct
                                                                                                           procedures for releasing
                                                                                                           information




                                                                                                       H6
                                                                                            Risk Register February 06
                                                                                                                                               Residual
                                                                                                                                                   Risk
Risk Area   Risk Description        Existing Controls                    Score   Cost      Lead          Action Required                                  Risk Status Progress                      Date
                                                                                 (000)                                                                                                              Complete



Security    Vulnerability re lack of Current asset register/SFI's        HIGH        300 DOF/SM          Update asset register/review         Mod         Active     Theft from security
            management of assets - standing orders. Existing security                                    security in key areas                                       highlighted weakness.
            potential for theft      arrangements                                                                                                                    Business case for security
                                                                                                                                                                     arrangements being formed

            Insufficient/outdated   Security staff, CSV, access control HIGH               DoO/SM        Risk assessment completed of         Low         Active     Risk assessments and
            security arrangements                                                                        all areas. Increased access                                 business cases being
                                                                                                         control. Upgrade and improve                                created
                                                                                                         CCTV s system
Risk/Safety Lack of competent       Risk manager/Head of Risk and        HIGH            35 ND           Appoint dedicated safety             Low         Accepted   Competent person in Risk       Septmber
            person                  Safety with Health and Safety                                        advised that meets H&S                                      manager, restructured          2005
                                    qualifications                                                       regulations                                                 department to recruit risk
                                                                                                                                                                     and safety manager

            Managers not           Advice from R&S department/Ad         HIGH            35 ND           Implement training programme         Low         Active     Currently developing
            competent to implement hoc training                                                          for all staff, concentrating of                             training programme. Brief
            Health and Safety                                                                            managers and safety                                         H&S training given to staff
            legislation                                                                                  representatives first                                       on orientation. Manager
                                                                                                                                                                     training offered
            Lack of suitable and    Trust does not meet management       HIGH            0 ND            Implement effective H&S              Low         Active     Risk assessment polices re-
            sufficient risk         regulations, DSE and COSHH                                           policies, ensure staff training in                          written, risk assessment
            assessments             regulations in relation to risk                                      how to conduct risk                                         tools created. Adhoc risk
                                    assessment                                                           assessments, monitor actions                                assessment currently
                                                                                                                                                                     undertaken by risk and
                                                                                                                                                                     safety department. To be
                                                                                                                                                                     first priority for safety
                                                                                                                                                                     adviser

            Breach pf Heath and     Trust being investigated and         HIGH     40000 DoO              Improved sharps management,          Low         Active     New policy implemented,
            safety at work act      potentiallp prosecuted for lack of                                   engagement by medical staff,                                new safer sharps bins
                                    complaince to HSWA                                                   suitable and sufficient risk                                introduced with risk
                                                                                                         assessments and training of                                 assessments and staff
                                                                                                         staff                                                       training
            Failure to learn from   Incident reporting, procedure,       HIGH              CH            Ensure risk register items are       Mod         Active     Next risk report (may ) will
            risks                   quarterly risk reports to governance                                 examined as part of capital                                 be joint
                                    trust board and CAB. Board                                           investment. Need to provide
                                    monitoring of serious incident                                       consolidated report on
                                    investigations                                                       incidents/complaints/claims




                                                                                                     H7
                                                                                          Risk Register February 06
                                                                                                                                                   Residual
                                                                                                                                                       Risk
Risk Area     Risk Description         Existing Controls                        Score   Cost      Lead          Action Required                               Risk Status Progress                       Date
                                                                                        (000)                                                                                                            Complete



              Risks from                 Meetings between Head of Risk          HIGH              DC/PC         Actions plans/outstanding risks HIgh          Active     Process needs to be
              internal/external audit    and Head of Internal Audit                                             need to be communicated to risk                          defined
              repoerts are not placed                                                                           and safety department
              on the trust risk register

EA            Non compliance to        Current waste management             HIGH        ?         DoO           Improve waste storage and         Low         Accepted   Latex was downscaled as a           May-05
legislation   special waste            education to staff re segregatoin at                                     handling, identify foul/surface                          risk and trust identified
              regulations              source, monotoring of authorised                                         drains. Improve hazardous                                process to comply
                                       carrier                                                                  waste compliance before EA
                                                                                                                revist in July 2005
Medical       Medical devices group.   Equipment management group.              HIGH        100 HOMP&E           Draw up and implement new        Low         Active     Policy created, awaiting
Devices       Poor organisation-wide   Trust policies                                                           policy. Establish equipment                              ratification. Equipment
              deployment, monitoring                                                                            library; set up physical space                           library staff appointed. Lead
              and control of medical                                                                            and test equipment, appoint                              nurse appointed
              devices                                                                                           staff.



              Inadequate training in   CNST assessment                          HIGH            10 HOMP&E       Establish new training            Low         Active     Systems still inadequate
              use of new devices.                                                                               procedures co-ordinated by                               and therefore difficulties in
              Inadequate training                                                                               medical equipment library staff                          achieving CNST
              records                                                                                           and lead nurses. Use medical                             compliance. Main issues re
                                                                                                                equipment library as central                             medical staff evidence
                                                                                                                reference point for training
                                                                                                                records.
Catering      Breach of food safety    Existing staff training                  HIGH        900 CM              catering staff to be trained in   Low         Accepted   Food hygiene courses run             Jun-05
(CA)          legislation                                                                                       food safety (within 6 months).                           and staff certificated
                                                                                                                                                                         displayed
Waste    Non compliance to             Education on waste segregation,          HIGH            0 SUP           Greater staff compliance to     Low           Active     Total waste contract being
manageme waste management              labelling of individual bags, official                                   segregation of waste. Tagging                            considered.
nt       regulation                    waste management contractor                                              system needed as current labels
                                                                                                                can be removed from bags

Medical       Non standard manifolds Current medical gas policies, staff        HIGH            50 DWO          To be replaced with British       Low         Active     Business plan agreed -
Gas           used Medical oxygen    training                                                                   standards                                                British standard manifolds to
                                                                                                                                                                         be fitted




                                                                                                            H8
                                                                                                 Risk Register February 06
                                                                                                                                         Residual
                                                                                                                                             Risk
Risk Area   Risk Description        Existing Controls                    Score   Cost     Lead          Action Required                             Risk Status Progress   Date
                                                                                 (000)                                                                                     Complete



Human       Lack of integrated       Internal learning and development   HIGH            0 DHR          Cannot control external learning Low        Accepted                    Feb-06
resources   education and learning strategy and learning and                                            (Royal college/nursing etc)
            strategy could lead to   development strategy group
            inappropriate investment
            in training




                                                                                                    H9
                                                                                         Risk Register February 06
                                                    Impact
                                       Likelihood
Risk Area   Risk        Existing                             Score   Cost (000)    Lead   Action
            Description Controls                                                          Required




                                                    MOD
                                       CERT
            Infection   No                                   MOD                  0 DON
            control     formal/com
            training    pulsory
                        training
                        given to
                        existing
                        staff as
                        part of
                        clinical
                        governanc
                        e or CPD.
                        All staff
                        involved in
                        direct
                        patient
                        care should
                        receive
                        appropriate
                        training in
                        Antimicrobi
                        al
                        Prescribing
                        and
                        Infection
                        control as
                        part of
                        clinical
                        governanc
                        e. CPD
                        and
                        winning
                        ways" but
                        dependent
                        on
                        obtaining
                        money for
                                                    MOD
                                       CERT




            Profession Organisatio                           MOD                  0 HOP
            al and      n should
            product     have a
            liability - policy that
            policy      covers all
                        relevant
                        issues of
                        professiona
                        l and
                        product
                        liability.
                        Preparation
                        of policy to
                        be done.
                                    MOD
                             CERT
P&P           To ensure                   MOD   0 HOP
liability -   register of
register      all goods
              and service
              providers
              maintained.
              To
              maintain
              existing
              register.




                                    MOD
                             CERT
P&P           Standard                    MOD   0 HOP
liability -   contract
contract      terms and
terms and     conditions
conditions    are always
              applied and
              reviewed.
              Service
              specificatio
              n to be
              reviewed.
                                    MOD
                             CERT




MD -          Equipment                   MOD   50 HOMP&E
training      failure or
              adverse
              incident
              arising
              from
              lacking or
              inadequate
              professiona
              l user
              training.
              Develop
              professiona
              l medical
              device user
              component
              of trust
              training
              strategy
              and
              implement
              appropriate
              programme
              s.
                                      MAJOR
                             UNLIKE
H&S policy - H&S policy -                     MOD   0 SAFEAD
financial    financial
             commitmen
             t.




                                      MAJOR
                             UNLIKE
H&S policy - H&S policy -                     MOD   0 D & GM
Senior       senior
manageme manageme
nt           nt
commitmen commitmen
t            t.




                                      MAJOR
                             UNLIKE
H&S policy - H&S policy -                     MOD   0 D & GM
training     training
needs        needs
analysis     analysis.




                                      MAJOR
                             UNLIKE

H&S policy - Dir/Div                          MOD   0 D & GM
Divisional policy - All
             to have
             own
             policies.
                                      MAJOR
                             UNLIKE




H&S policy - Dir/Div                          MOD   0 D & GM
Divisional policy -
             Staff to
             know about
             policy
                                      MAJOR
                             UNLIKE




H&S policy - Drs to be                        MOD   0 MDHR
Staff        made
awareness aware of
             policy.
                                      MAJOR
                             UNLIKE




H&S policy - Consultatio                      MOD   0 D & GM
consultatio n of staff
n of staff   and safety
             reps on
             H&S
             matters -
             H&S
             training
             and
             information
             to be
             provided
             for staff.
                                      MAJOR
                             UNLIKE




H&S -         Complianc                       MOD   0 D & GM
compliance    e with
with          legislation.
legislation   Inspections
              to be
              carried out.
                                        MAJOR
                               UNLIKE
H&S -          Complianc                        MOD   0 D & GM
compliance     e with
with           legislation -
investigatio   inspections
n              to be
               carried out.




                                        MAJOR
                               UNLIKE
H&S policy - Incident                           MOD   0 CLIGOV
incident     manageme
manageme nt. LACs
nt           fully
             informed
             about
             RIDDOR.




                                        MAJOR
H&S -          Serious/im      UNLIKE           MOD   0 DOP&GM
serious/im     minent
minent         danger -
danger         Table top
               exercises
               for all
               major
               emergenci
               es.
                                        MAJOR
                               UNLIKE




Manual         Staff to be                      MOD   0 DHR
handling -     made
staff aware    aware of
of policy      manual
               handling
               policy.
                                        MAJOR
                               UNLIKE




Manual         Manual                           MOD   30 DHR
handling -     handling -
Sufficient     sufficient
competent      competent
advice         advice
               (additional
               cost per
               year)
                                        MAJOR
                               UNLIKE




Manual         Manual                           MOD   0 DHR
handling -     handling -
Risk           risk
assessmen      assessmen
ts             ts (cost
               included
               above)
                                        MAJOR
                               UNLIKE




Manual         Manual                           MOD   0 GM
handling -     handling.
Individual     Individual
patient        patient
assessmen      assessmen
ts             ts to be
               carried out.
                                     MAJOR
                            UNLIKE
Manual    Manual                             MOD   100 D & GM
handling  handling.
equipment Sufficient
          manual
          handling
          equipment.




                                     MAJOR
                            UNLIKE
Manual       Manual                          MOD    0 DHR
handling     handling.
training     Training for
             all staff
             (costs
             included
             above)




                                     MOD
                            LIKELY
HU -      Harassmen                          MOD    0 DHR
harassmen t. Further
t         work to
          prevent
          and tackle
          harassmen
          t.
                                     MOD
                            LIKELY




HU - staff   Staff                           MOD    0 DF
sickness     sickness
             rates. Fully
             implement
             absence
             monitoring
             system.
                                     MOD
                            LIKELY




HU -         Violence -                      MOD    0 DWO
violence     further
             work to
             reduce
             violence
             against
             staff.
                                     MOD
                            LIKELY




External     Tripping                        MOD   300 DWO
road         hazard,
surfaces     repairs to
             be carried
             out.
                                     MOD
                            LIKELY
MD -         Equipment                     MOD   250 HOMP&E
inadequate   failure due
maintenanc   to
e            inadequate
             planned
             preventativ
             e
             maintenanc
             e. Re-
             negotiate
             or withdraw
             from
             contract
             with CNA -
             enhance
             trust's in-
             house
             medical
             electronics
             and
             equipment
             manageme
             nt service
             to meet the
             needs of
             the trust
             (seen by
             CNA as
             most cost
             effective
             equipment
             manageme
             nt
             mechanism
             ).
                                     MOD
                            LIKELY




HU -         Developme                     MOD    0 DHR
Developme    nt and
nt &         training.
training     Achieve full
             coverage
             of
             performanc
             e and
             developme
             nt planning.
                                   MOD
                          LIKELY
P&P -       Monitored                    MOD   0 HOP
manageme    by
nt and      manageme
board       nt and the
            board to
            make
            improveme
            nts.
            Controls
            assurance
            return will
            raise
            awareness.




                                   MOD
                          POSS
P&P -       Staff are                    MOD   0 HOP
training    provided
            with
            training on
            liability
            issues.
            Training
            needs
            analysis to
            be
            undertaken
            . Training
            to be
            provided.
                                   MOD
                          POSS




P&P - Risk Key                           MOD   0 HOP
indicators performanc
           e and/or
           risk
           indicators
           are used at
           all levels.
           New stores
           computer
           will provide
           indicators
           on
           performanc
           e.
                                   MOD
                            POSS
Security -   This                        MOD   0 SUP
Training     training is
             currently
             theoretical
             not
             practical.
             There is a
             risk that
             staff may
             injure
             themselves
             /patients
             whilst using
             restraint
             techniques.
             A
             programme
             is being
             developed
             with staff
             education
             to ensure
             staff
             working in
             high risk
             areas
             receive
             instruction
             in control
             and
             restraint
             techniques.
                                   MOD
                            POSS




PS -         Training                    MOD   0 HOP
Training     provided to
             employees.
             Maintain
             assessmen
             t and
             training
             programme
             s.
                                    MOD
                             POSS
Risk         Need to                      MOD    0 DECONT
manageme     establish
nt in        risk
decontamin   processes
ation        in
             decontamin
             ation
             including
             risk
             treatment
             plans to
             identify
             risks.




                                    MOD
                             POSS
Major        Insufficient                 MOD   500 RPA
incident     testing of
plan         major
             incident
             plan. Test
             MI plan.
                                    MOD
                             POSS




MD -         Failure of                   MOD   50 HOMP&E
equipment    safe
manageme     equipment
nt           manageme
             nt from lack
             of trust-
             wide
             information
             availability.
             Extend
             medical
             electronics
             inventory
             database
             to cover
             non-
             electronic
             medical
             devices.
             Increase
             availability
             to technical
             and non-
             technical
             users via
             trust
             network.
             Consider
             batch-
             logging of
             single use
             devices
             (supplies
             dept - no
             cost
             indicated).
                               MOD
                        POSS
MD -     Inadequate                  MOD   0 PATHO
Unsafe   , inaccurate
data     or unsafe
         data from
         invitro
         diagnostic
         point of
         care
         devices.
         Agree trust
         policy on
         manageme
         nt of point
         of care
         service.
         Ensure
         necessary
         quality
         assurance
         staff are
         appointed.
         Part of PoC
         policy
         taken to
         trust board.
                                   MOD
                            POSS
MD -         Exposure                    MOD   250 DECONT
contaminat   of staff to
ed medical   contaminat
devices      ed medical
             devices.
             Establish
             decontamin
             ation
             procedures
             ; appoint
             decontamin
             ation
             manager;
             build and
             staff
             decontamin
             ation
             facility for
             general
             purpose
             medical
             devices
             under
             aegis of
             decontamin
             ation
             manager.
                                   MOD
                            POSS
MD - point   Inadequate                  MOD   0 HOMP&E
of care      or wrong
devices      patient
             diagnosis
             from lack of
             user
             training in
             point of
             care
             devices.
             Agree trust
             policy on
             manageme
             nt of point
             of care
             service.
             Set up
             training
             and
             competenc
             e
             assessmen
             t
             programme
             . Develop
             record-
             keeping
             programme
             to
             document
             this.
                                  MOD
                           POSS
MD - Early Equipment                    MOD   40 HOMP&E
warning    failure or
system     adverse
           incident
           arising
           from lack of
           system for
           giving early
           warning of
           risk.
           Extend
           medical
           electronics
           inventory
           database
           and points
           of access
           to it and
           systems of
           input to it -
           to cover
           proactive
           risk
           analysis.
           Appoint
           risk
           assessmen
           t staff
           member to
           medical
           electronics
           and
           equipment
           manageme
           nt.
                                     MOD
                              POSS
MD - risk Equipment                          MOD   10 HOMP&E
manageme failure or
nt        adverse
          incident
          arising
          from lack of
          effective
          risk
          manageme
          nt of
          medical
          devices.
          Develop
          risk
          analysis
          and
          monitoring,
          develop
          understand
          ing of trust
          risk
          register.
                                     MOD
                              POSS




Nurse/pers No link                           MOD   0 DON
onnel link nurse/pers
           onnel
           system.
                                     MOD
                              POSS




Inadequate Inadequate                        MOD   35 DOS
database database
support    support for
           surveillanc
           e. Need
           ICNet
           infection
           control
           software
           packages.
           Need
           access
           database
           support.
                                     MAJOR
                              RARE




Health and     H&S                           MOD   0 HR
safety -       Director to
board          take
responsibili   responsibili
ty             ty.
                                   MAJOR
                            RARE
Catering     Possibility                   MOD   0 CM
risk         of dish
             being
             served
             without
             hazard
             being
             identified
             and
             therefore
             controls not
             in place.
             Individual
             dish risk
             assessmen
             t required
             (currently
             one risk
             assessmen
             t for all
             food
             served).
                                   MAJOR
                            RARE




P&P -        All goods                     MOD   0 HOP
packaging    provided
requiremen   are
ts           packaged
             in
             accordance
             with
             relevant
             regulatory
             requiremen
             ts.
             Maintain
             existing.
                            4




                                   2




Inpatient    Nursing                       SIG   0 GM
falls        observation

             Falls
             assessmen
             t tool.
             Cotsides.
             Call bell.
    Risk
Residual
           Risk Status Progress   Date
                                  Complete