Risk Management Appendix A - South London and Maudsley NHS by taoyni

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									            SOUTH LONDON AND MAUDSLEY NHS TRUST                                                                   DRAFT RISK REGISTER




Number/
Source *                                                                                                                                                            Impact Likeli- =                                            Current             Independent
           Risk Name             Risk Type   Description/Objective                  Directorate     Location      Risk Owner         Existing Controls                x    hood Rating Action Plan                              Progress            Assurance
                                             Elimination of suicide by patients                                                      Clinical risk assessment;                         See Safer Services Action Plan           See Safer           MHA
                                                                                    All Clinical                                     brief risk screen                                                                          Services Action     Commission/
CL1        Suicide of patients   Clinical                                                           Trust-wide    David Roy                                           5       5      25                                         Plan                CHI
                                                                                    Directorates

                                             Reduction in violent incidents                                                        Zero Tolerance/ Preventing                             See Zero Tolerance/ Preventing &      Zero Tolerance/ NPSA/ HSE
                                             towards staff & patients                                                              & Managing Violence                                    Managing Violence & Aggression        Preventing &
INC1       Violence              Clinical                                           Trust-wide      Trust-wide    Hilary McCallion Policy; Training; Clinical         4       5      20   plans                                 Managing
                                                                                                                                   Risk Assessment                                                                              Violence plans

                                             Reduction in injuries to patients &                                                     Ongoing training                                     No Action Plan                        Not known           MHA
           Control & Restraint -             staff when C&R used                                                                                                                                                                                    Commission/
NURS3                            Clinical                                           Nursing         Trust-wide    Hilary McCallion                                    4       4      16                                                             CHI
           use

                                             Increased demands/service                                                               None                                                 Review increase and projection of     Funding for staff
                                             developments from Boroughs do not                                                                                                            service developments that impact      approved -
           Pharmacy - Service                include funding for Pharmacy          Specialist                                                                                             on Pharmacy; build into Business      awaiting
SPEC27                        Clinical                                                              Trust-wide    David Taylor                                        4       4      16
           Development                       services - could result in no service (Pharmacy)                                                                                             plans                                 recruitment
                                             being available.
                                             Correct segregation of waste                                                            Waste segregation training                           Introduction of Trust Waste policy;   Transport of        EHO
           Waste disposal -                                                                                                                                                               Training; recommendations from        Dangerous
INFC7                            Clinical                                           Trust-wide      All           Barry Huckstep                                      4       4      16   Dangerous Goods review to be          Goods review
           Clinical
                                                                                                                                                                                          incorporated into Trust Policy.       completed.

                                             Allegations of assault on Child &                                                       Criminal records checking;                                                                 Not known           Internal Audit
           Children - Assault by             Adolescent in-patients                                 CAMHS In-                        training & supervision;
CAMHS1                           Clinical                                           CAMHS                         Judith Bowden      professional standards;          3       5      15
           staff/patients                                                                           patient wards
                                                                                                                                     limiting agency staff

                                             Safety of staff, patients and public                                                    Clinical Risk Assessment;                            Policy in development                 Not known           CHI
                                             when escorting patients away from                                                       Observation; Local policies
TP9        Escorting Patients    Clinical    Trust premises                         All             Trust-wide    Hilary McCallion                                    5       3      15


                                             Potential ligature points on in-patient                                                 Ligature point audits; all                           Ligature point audit to be            Audits underway PEAT/ CHI
                                             units                                   All Clinical                                    shower & bed curtains                                completed; Ligature point removal
CG2        Ligature points       Clinical                                                           Trust-wide    Cliff Bean         collapsible                      5       3      15   strategy to be agreed
                                                                                     Directorates

                                             To eliminate number of serious                                                        Patient Observation Policy;                            Audit awareness and use of            Audit of ligature CNST
           Observation Policy -              incidents where patient observation    All Clinical                                   guidelines laid down by                                observation policy. Review            points across
CLA6                            Clinical     is inadequate                                          Trust-wide    Hilary McCallion professional bodies                5       3      15   observation policy in the light of    the Trust
           adherence to                                                             Directorates
                                                                                                                                                                                          incidents, complaints & claims

                                             Reduce substance misuse on in-                                                          Trust policy and training                            To be agreed                          Review local
                                             patient areas                          All Clinical                                     package                                                                                    policies. Work
SOU7       Substance Misuse      Clinical                                                           Trust-wide    Hilary McCallion                                    3       5      15                                         with Police re
                                                                                    Directorates
                                                                                                                                                                                                                                searching

                                             To improve communication between                                                        CPA documentation                                    No Action Plan                        Not known
           SUI's involving                   clinical team and client's family All Clinical
CLA7       patients in           Clinical                                                           Trust-wide    Hilary McCallion                                    5       3      15
                                                                               Directorates
           community

                                             Appropriate window restraints &                        Estates &                        Health & Safety legislation;                         Audit in-patient and OPD areas;       Not known           MHA
           Windows - Use of                  locks fitted                                                                            Safer Services; Internal                             refit with appropriate windows,                           Commission
                                                                                                    Facilities;
CLA5       windows to abscond Clinical                                              Trust-wide                    Roy Jaggon         design standards                 3       5      15   locks and restraint mechanisms
                                                                                                    Capital
           from ward
                                                                                                    Projects




            * See Key attached                                                                                           Page 1 of 13                                                                             06/12/2002             APPENDIX A
            SOUTH LONDON AND MAUDSLEY NHS TRUST                                                                   DRAFT RISK REGISTER




Number/
Source *                                                                                                                                                            Impact Likeli- =                                              Current            Independent
           Risk Name             Risk Type   Description/Objective                   Directorate   Location       Risk Owner         Existing Controls                x    hood Rating Action Plan                                Progress           Assurance
                                             Failures in Child Protection practice                                                   Part 8 enquiries &                                 No Action Plan                            Not known          Child
                                             & procedures                                          CAMHS                             recommendations; prof                                                                                           Protection
CAMHS2     Child Protection      Clinical                                            CAMHS         Community      Judith Bowden      standards; Child Protection      3      4     12                                                                Teams
                                                                                                   sites                             Policy; Training

                                             Policy for communicating with and                                                       Some guidance in Consent                           No Action Plan                            Not known          StHA's
           Communication &                   interpreting services for non-English                                                   Policy
TP5        Interpreting Policy   Clinical    speaking clients                      All             Trust-wide     Zoe Reed                                            3      4     12
           (18)

                                             Patients delayed on wards awaiting                                                      Ongoing discussions with                           Ward Round Audit being                    Audit to be        MHA
           Delayed Discharges                care packages/transfer to nursing                     All MHOA                          Social Services                                    undertaken. To be discussed at            discussed at       Commission/
MHOA7                         Clinical       home                                    MHOA                         David Norman                                        3      4     12   Clinical Governance meeting.              next Clinical      CHI
           - MHOA                                                                                  wards
                                                                                                                                                                                                                                  Gov. Meeting

                                             Current lack of MH Electronic                                                           Paper records                                      ICT to urgently prioritise the roll out CPA / CCS            CNST
           Electronic Patient                Record in certain Croydon service       Croydon                                                                                            of CCS in Croydon                       Group now
CRO11                            Clinical    areas. Especially in Forensic                         Croydon        Mike Denis                                          4      3     12                                           meeting
           Records - Croydon                                                         AMH
                                             services                                                                                                                                                                           regularly

                                             Reduction in the number of                                                              Professional standards;                            Trust-wide Medication Policy being Not known                 CNST
           Medication -                      medication administration errors                                                        local policies                                     developed
NURS2      Administration        Clinical                                            Nursing       Trust-wide     Hilary McCallion                                    4      3     12
           errors

                                             Minimise mistakes in medication                                                         Dispensing procedures.                             Standardise dispensary practice           Continuous         CNST
           Medication -                      dispensing                                                                              Internal error monitoring.                         Trust-wide, Internal error                internal error
                                                                                     Specialist    Pharmacy
SPEC9      Dispensing errors     Clinical                                                                         David Taylor       Few accredited                   4      3     12   monitoring, accreditation of all staff,   monitoring
                                                                                     (Pharmacy)    dispensary
           (Pharmacy)                                                                                                                technicians.                                       effective IT system                       system

                                             Reduce medication errors - Patient                                                                                                         See Pharmacy Service Plan -               Awaiting new       CNST
           Medication -                      identifiers / Access to medication                                                                                                         Michell Mehta                             computer
                                                                                     Specialist    All Clinical
SPEC12     Pharmacy - IT /       Clinical    records and reduce transcription                                     David Taylor                                        4      3     12                                             system
                                                                                     (Pharmacy)    areas
           CCS access                        errors

                                             Increase identification of prescribing                Pharmacy,                         Pharmacist screens all                             Increase clinical pharmacist         Ongoing                 CNST
           Medication -                      errors and reduce incidence of         Specialist     Wards,                            prescriptions. Permanent                           services, certificate in Pharmacy
SPEC10                           Clinical    medication errors.                                                   David Taylor       pharmacists require cert. in     4      3     12   Practice, audit of clinical pharmacy
           Prescription errors                                                      (Pharmacy)     Community
                                                                                                   teams                             pharmacy practice.                                 services and prof. standards

                                             Implementation of MHA by nursing                                                        Professional standards                             No Action Plan                            Not known          MHA
           Mental Health Act -               staff, including consent and code of                                                                                                                                                                    Commission
NURS11     implementation by     Clinical    conduct issues                          Nursing       Trust-wide     Hilary McCallion                                    4      3     12
           nurses

                                             Proper assessment of physical                                                           Professional standards                             No Action Plan                            Not known          CHI
           Physical health                   health needs of users
NURS7                            Clinical                                            Nursing       Trust-wide     Hilary McCallion                                    4      3     12
           needs of users

                                             Potential traumatic wound in                                                            Basic clinical training                            Recruit Tissue Viability Nurse;           Identify funding   CHI
           Wound                             Patient/client                                                                                                                             Training                                  for post;
INFC5                            Clinical                                            Trust-wide    All            Hilary McCallion                                    3      4     12                                             Recruitment to
           management
                                                                                                                                                                                                                                  post

                                             Lack of X-ray facilities on the BRH                                                     Use of alternative X-ray                           Urgently examine options to               To be raised     CNST
                                             site.                                   Croydon                                         facilities                                         introduce X-ray facilities on BRH         with Facilities
CRO13      X-ray facilities      Clinical                                            AMH, MHOA, Bethlem           Roy Jaggon                                          3      4     12   site                                      and option paper
                                                                                     Specialist                                                                                                                                   produced




            * See Key attached                                                                                           Page 2 of 13                                                                           06/12/2002                  APPENDIX A
            SOUTH LONDON AND MAUDSLEY NHS TRUST                                                                   DRAFT RISK REGISTER




Number/
Source *                                                                                                                                                        Impact Likeli- =                                          Current           Independent
           Risk Name             Risk Type   Description/Objective                    Directorate    Location     Risk Owner      Existing Controls               x    hood Rating Action Plan                            Progress          Assurance
                                             Financial overspend                                                                Borough/Directorate                                 Detailed recovery plan                Monthly          Internal Audit
                                                                                                                                financial and performance                                                                 meetings and
SOU3       Financial Risk        Financial                                            All            Trust-wide   Tim Greenwood monitoring meetings               4      5     20                                         progress against
                                                                                                                                                                                                                          plan

                                             Trust has picked up the financial risk                                             Trust wide Forensic                                 Detailed plan                         Gatekeeping of    Internal Audit
           Forensic Financial                of OATS placements                                                                 Performance Management                                                                    new referrals.
SOU2                             Financial                                            All            Trust-wide   Tim Greenwood meeting                           4      5     20                                         OATS team in
           Risk
                                                                                                                                                                                                                          place

                                             Centrally agreed cost pressures                                                      Identified cost pressure                          Identify increased income stream      Not known         Internal Audit
           Unfunded posts (ex-               exist within a number of main income Specialist         Bethlem,                                                                       with Finance. Secure income
SPEC3                          Financial     generating services.                                                 Mark Allen                                      4      5     20   budget to the Directorate.
           Culyer) - National                                                     (National)         Maudsley

                                             Waiting list initiative. A number of                                                 Identified cost pressure                          Ensure waiting list targets are met. Ongoing           Internal Audit
           Unfunded posts                    posts have been established at risk                                                                                                    Negotiate with PCTs regarding        negotiations with
                                                                                      Specialist     Bethlem,
SPEC1      (waiting list) -      Financial   to address long waiting lists                                        Mark Allen                                      4      5     20   additional funding.                  PCT to secure
                                                                                      (National)     Maudsley
           National                                                                                                                                                                                                      income

                                             Inadequate security in Cashiers                                                      Current security assessed                         To be reviewed and actioned by        Not known         Internal Audit
                                             Offices                                  Finance &      Bethlem,                     as inadequate                                     Finance & Corporate Governance
           Cashiers - Staff
SCA14                            Financial                                            Corporate      Maudsley     Tim Greenwood                                   4      4     16
           injury/loss of cash
                                                                                      Governance     Lambeth

           Charitable fund                   Inadequate asset records,                                                            Responsibilities and budget                       Management of Trust fund property Not known             District Audit/
                                             insurance, maintenance provision         Finance &                                   provision uncertain                               title deeds, insurance, maintenance                     Internal Audit
           assets - Losses                                                                           Trustee
SCA15                            Financial   etc.                                     Corporate                   Tim Greenwood                                   4      4     16   etc to be made effective.
           through failure to                                                                        properties
                                                                                      Governance
           safeguard

           Financial loss                    Key Financial Controls not Identified                                                Out of date/ incomplete                           Procedures will be written in line    Not known         Internal Audit
                                             in procedures and followed            Finance &                                      procedures                                        with the action points arising from
           including fraud
SCA7                             Financial                                         Corporate         Trust-wide   Tim Greenwood                                   4      4     16   Trust audit reports
           /inaccurate
                                                                                   Governance
           accounting
                                             Hepatitis B service funding agreed to                                                Identified cost pressure                          Negotiate with MH services and        Review            Internal Audit
                                             April 2003                                                                                                                             DAT                                   continues
           Funding - Hepatitis                                                        Specialist     Addictions
SPEC21                           Financial                                                                        Marilyn Major                                   4      4     16
           B                                                                          (Addictions)   Services


                                             Lambeth Dual Diagnosis service                                                       Identified cost pressure                          MH resource needs flagged up          Review            Internal Audit
           Funding - Lambeth                 funding agreed to April 2003             Specialist                                                                                                                          continues
SPEC20                           Financial                                                           Lambeth      Marilyn Major                                   4      4     16
           Dual Diagnosis                                                             (Addictions)

                                             Smoking Cessation Clinic funding                                                     Identified cost pressure                          Discuss at quarterly review           Next meeting      Internal Audit
           Funding - Smoking                 agreed to April 2003                     Specialist                                                                                    meetings across 7 Boroughs            9/12/02
SPEC22                           Financial                                                           Maudsley     Marilyn Major                                   4      4     16
           Cessation                                                                  (Addictions)

                                             Under reporting of activity on PAS                                                   Some reported activity                            Arrange additional training for all   All admin staff   Internal Audit
           PAS Data Quality -                leading to lost income                   Specialist     Specialist                                                                     admin staff. Closer monitoring of     had additional
SPEC4                            Financial                                                                        Mark Allen                                      4      4     16   data quality and data input.          training. Data
           National                                                                   (National)     (National)
                                                                                                                                                                                                                          quality checks.

                                             Income from catering contractors                                                     Position being clarified                          Position to be resolved               Not known         Internal Audit
                                             less than contract conditions            Finance &
           Catering Income                                                                           Bethlem,     Tim Greenwood
SCA21                            Financial                                            Corporate                                                                   3      5     15
           Shortfall                                                                                 Maudsley     /Roy Jaggon
                                                                                      Governance




            * See Key attached                                                                                           Page 3 of 13                                                                      06/12/2002              APPENDIX A
            SOUTH LONDON AND MAUDSLEY NHS TRUST                                                                  DRAFT RISK REGISTER




Number/
Source *                                                                                                                                                           Impact Likeli- =                                           Current          Independent
           Risk Name            Risk Type    Description/Objective                   Directorate   Location      Risk Owner          Existing Controls               x    hood Rating Action Plan                             Progress         Assurance
                                             Access to high quality data reporting                                                   Access to limited activity                        ICT to ensure Directorate reporting    Additional PAS   Internal Audit
           Information                       required so that accurate activity                                                      data                                              requirements produced &                reports being
                                                                                                   Specialist    Mark Allen /
SPEC7      Reporting -          Financial    levels are used to secure funding.    Specialist                                                                        3      5     15   maintained to required level. Action   developed and
                                                                                                   (National)    Mike Denis
           Specialist                        Specifically BOMIC, PAS, CCS.                                                                                                             plan, lead & funding agreed.           validated.

                                             Key control account reconciliations                                                     All control ac's get same                         Control account schedule to be set Not known            Internal Audit
                                             not performed/ reviewed regularly       Finance &                                       priority                                          up, which will identify key control
           Accounting -
SCA6                            Financial                                            Corporate     Finance       Tim Greenwood                                       3      4     12   a/cs
           Inaccurate
                                                                                     Governance

                                             Deliver service to client group                                                                                                           No Action Plan                         Recruitment     Internal Audit
           Agency Nursing                    without additional drain on financial                 Directorate                                                                                                                campaigns.
LAM8                            Financial    resources /Peg agency rates             Lambeth                     Maresa Ness                                         4      3     12                                          Encourage staff
           Rates - Lambeth                                                                         wide
                                                                                                                                                                                                                              to join bank.

                                             Ensure adequate performance to                                                          Regular meetings;                                 No Action Plan                         Not known        Internal Audit
                                             contract by building contractors        Finance &                                       performance mgmt;
           Building Contractors
CAP3                            Financial                                            Corporate     Trust-wide    Roy Jaggon          planning; change control;       4      3     12
           - performance
                                                                                     Governance                                      penalty clauses

           Creditor payment                  Fraudulent use of dormant supplier                                                      Amendment rights limited                          To develop procedures to archive       Not known        Internal Audit
                                             records left live                       Finance &                                       to supervisory staff                              accounts without movement for 12
           supplier records -
SCA23                           Financial                                            Corporate     Finance       Barry Ashworth                                      4      3     12   months
           Fraudulent use of
                                                                                     Governance
           dormant records
                                             Establishment reviews required in all                                                                                                     All wards to review establishments, Not known           Internal Audit
           Establishment                     areas due to high excess nursing                                                                                                          shift patterns and rostering.
SPEC8                           Financial    expenditure and change in casemix. Specialist         Specialist    Mark Allen                                          3      4     12   Consider revised establishments in
           Reviews - Specialist
                                                                                                                                                                                       review of service tariffs

                                             Inappropriate definition of                                                       Exec to reappraise Service                              Exec to reappraise Service &           Not known        Internal Audit
                                             responsibilities; Income issues -        Finance &    Finance/
                                                                                                                 Tim Greenwood & Capital Planning role                                 Capital Planning role
SCA20      Income Shortfall     Financial    Identification, costing, negotiation etc Corporate    Service                                                           4      3     12
                                                                                                                 /Roy Jaggon
                                                                                      Governance   Planning

                                             Reduction in problems with nursing                                                      Policies in place                                 Develop a standard written control     Not known        Internal Audit
                                             staff handling Trust and clients        Finance &                                                                                         procedure for general adoption
NURS15     Money handling       Financial    monies                                  Corporate     Trust-wide    Tim Greenwood                                       4      3     12
                                                                                     Governance

                                             Improved SLA/Contract monitoring                                                        Monitoring of                                     Service planning dept. to provide      Improved         Internal Audit
           SLA/Contract                      to ensure balance between income & Specialist         Specialist                        SLA/Contracts                                     up-to-date information. Expect to      reporting.
SPEC15                           Financial   activity                                                            Mark Allen                                          3      4     12   have income match activity by April    Regular SLA
           monitoring - National                                                (National)         (National)
                                                                                                                                                                                       2003.                                  monitoring.

                                             Long distance / International call                                                      Telecom review                                    Usage to be analysed.                  Not known        Internal Audit
           Telephones -                      costs may not be effectively                                                            commissioned & reported                           Responsibilities to be allocated for
SCA2                           Financial     controlled                              ICT           Trust-wide    Mike Denis          to Exec.                        4      3     12   monitoring usage
           unauthorised use of

                                             Lack of co-ordinated training plan                                                      Patchy training & planning;                       Consultants commissioned to            Not known        Internal Audit
           Training -                                                                                                                PDP based training                                review this area
SCA4       Inappropriate/ non   Financial                                            Training      Trust-wide    Hillary McCallion                                   3      4     12
           cost effective

                                             Reduction in high, and often                                                            Review of spend on                                Implementation of new Trust policy. Not known           Internal Audit
           Transport & taxi                  unbudgeted, transport & taxi                                                            minicabs completed                                Review high spending teams.
SPEC18     expenditure -        Financial    expenditure.                            Specialist    Trust-wide    Mark Allen                                          3      4     12   Examine alternatives.
           Specialist




            * See Key attached                                                                                          Page 4 of 13                                                                          06/12/2002              APPENDIX A
            SOUTH LONDON AND MAUDSLEY NHS TRUST                                                                    DRAFT RISK REGISTER




Number/
Source *                                                                                                                                                            Impact Likeli- =                                          Current          Independent
           Risk Name             Risk Type   Description/Objective                    Directorate     Location     Risk Owner         Existing Controls               x    hood Rating Action Plan                            Progress         Assurance
                                             To meet COSHH standards for                                                              Partial compliance                                Develop central register              Not known        HSE
                                             storage & use of harmful substances Finance &
EF5        COSHH - E&F           H&S         within Estates & Facilities         Corporate            Trust-wide   Roy Jaggon                                         4      4     16
                                                                                 Governance

                                             Increased safety for lone workers                                                        Community Working Policy                          Develop lone worker policy            Not known        HSE
                                             and issues re clients privacy and
NURS13     Lone workers          H&S         dignity                                  Nursing         Trust-wide   Hilary McCallion                                   4      4     16


                                             Lack of working space leading to                                                         Health & Safety risk                              Modernisation of dept. on hold for 4 Not known         HSE
           Pharmacy - lack of                stress; manual handling problems;                        Pharmacy,                       assessment completed                              years. H&S issues to be resolved.
SPEC5                            H&S         unsuitable furniture & workstations;     Specialist                   Roy Jaggon                                         4      4     16
           working space                                                                              BRH
                                             unsuitable exit - fire risk

                                             Improve stress management for                                                            Improving Working Lives,                          No Action Plan                        Not known        HSE
           Stress management                 nursing staff                                                                            Health and Safety
NURS19                       H&S                                                      Nursing         Trust-wide   Hilary McCallion                                   4      4     16
           - nursing

                                             Lack of seclusion room; resus trolley                                                    Estates & Facilities Health                       Looking for appropriate relocation    Not known        HSE
           Weston Unit -                     on Job Ward not accessible;                              Weston Unit,                    & Safety assessment on                            site.
SPEC6                            H&S         appropriate space; welfare facilities; Specialist                     Mark Allen         unit                            4      4     16
           facilities                                                                                 Guy's
                                             unsatisfactory heating & lighting

                                             To reduce number of injuries                                                             Content of training                               Review training programme             Under            Ashworth
           Control & restraint -             claimed as a result of attending C&R All Clinical        Training                        programme                                         content; sign off at end of course    discussion       training
CLA3                             H&S         courses                                                               Hilary McCallion                                   3      5     15                                                          programme
           training                                                               Directorates        Dept
                                                                                                                                                                                                                                               accreditation

           Falls, Slips                      To reduce number of claims                                                               Health & Safety legislation                       Consider slip audit; work with        Not known        HSE
           (particularly wet                 resulting from slips                                                                                                                       Mediclean and Trust staff to identify
CLA2                             H&S                                                  Trust-wide      Trust-wide   Roy Jaggon                                         3      5     15   key areas of concern and to
           floors) and trips
           (outcome)                                                                                                                                                                    improve alert procedure

                                             Existing windows are not secure and                                                      Project mgmt                                      Work now taking place.                Two weeks        HSE
           Ladywell Unit -                   have led to six SUIs                                                                     arrangements - lack of                                                                  behind schedule.
LEW2                           H&S                                                    Lewisham        Ladywell Unit Tracey Power      continuity; project over a      5      3     15
           window safety works
                                                                                                                                      year behind schedule.

                                             Implement procedures to minimise                         All                             Trust and Local                                   Investigate possibility of personal   Being taken      HSE
           Lone staff risk of                risks to lone staff in Supported                                                         Procedures                                        alarm systems                         forward by
                                                                                                      Supported
LAM5       attack in Supported H&S           Housing                                  Lambeth                      Maresa Ness                                        5      3     15                                         Rehab
                                                                                                      accomm-
           Housing                                                                                                                                                                                                            Management
                                                                                                      odation
                                             Reduction in number of accidents                                                         Manual Handling Policy.                           Policy Implementation. Training to    Consultants      HSE
                                             due to incorrect manual handling;                                                        Some awareness training                           raise staff awareness                 report to be
HS4        Manual Handling       H&S         failure to comply with the Manual        Trust-wide      Trust-wide   Ron Moody          already carried out by the      3      5     15                                         presented to
                                             Handling Operations Regulations.                                                         Trust                                                                                   Exec

                                             Lack of workspace, interview rooms,                                                                                                        Need to relocate - working with       Project Officer in HSE
           Premises -                        welfare facilities for staff and clients; Specialist                                                                                       Capital Planning                      post.
SPEC25                           H&S         Fire hazard in basement.                                 Catford      Marilyn Major                                      3      5     15
           Addictions, Catford                                                         (Addictions)
                                             Environmental hazards; security

                                             High level of falls reported                                                             Reported at H&S meetings.                         Detailed review to be undertaken.     Physio to       Clinical Audit
           Falls in Wards -                                                                           All MHOA                        Physio to look at all falls                       Head injury training programme.       feedback. Falls
MHOA2                            H&S                                                  MHOA                         David Norman       and causes                      3      4     12                                         monitored and
           MHOA                                                                                       wards
                                                                                                                                                                                                                              fedback to H&S




            * See Key attached                                                                                            Page 5 of 13                                                                         06/12/2002             APPENDIX A
            SOUTH LONDON AND MAUDSLEY NHS TRUST                                                                   DRAFT RISK REGISTER




Number/
Source *                                                                                                                                                        Impact Likeli- =                                          Current           Independent
           Risk Name              Risk Type   Description/Objective                   Directorate   Location      Risk Owner      Existing Controls               x    hood Rating Action Plan                            Progress          Assurance
                                              Continuous assessment & improved                                                    Partial compliance                                Maintain systems; provide budget & Not known            HSE
                                              operational management of fixed  Finance &                                                                                            action plan; audit
           Fixed installation
EF7                               H&S         installation testing             Corporate            Trust-wide    Roy Jaggon                                      4      3     12
           testing
                                                                               Governance

                                              Failure to comply with Management                                                   Awareness Training                                Awareness training for Managers.      Started           HSE
           H&S Risk                           of Health & Safety at Work                                                                                                            Risk Assessor Training for those
HS3                               H&S         Regulations                             Trust-wide    Trust-wide    Ron Moody                                       4      3     12   employees involved in Assessing
           Assessment
                                                                                                                                                                                    H&S Risks

                                              Failure to comply with HSE                                                          Monitoring of progress by                         Develop risk assessments;             Operational       HSE
                                              improvement notices served              Finance &                                   Risk Management                                   schedule & evidence of training       group is
           H&S Statutory
HS1                               H&S                                                 Corporate     BRH           Roy Jaggon      Committee                       4      3     12                                         progressing
           compliance - BRH
                                                                                      Governance                                                                                                                          Action Plan

                                              H&S Risk Assessments/assessors                                                      Some registers in place                           H&S Advisors recruited.               Registers being HSE
           Health & Safety -                  in place                                Finance &                                                                                                                           developed
EF1        E&F Risk               H&S                                                 Corporate     Trust-wide    Roy Jaggon                                      4      3     12
           Management                                                                 Governance

                                              Health and Safety. Statutory                                                        Statutory compliance                              Conduct round of statutory            Work started in   HSE
           Health & Safety -                  Compliance [7,10,22,23,24]              Finance &                                   monitoring                                        compliance audits (inc pre-HSE        Estates
CA43       Statutory              H&S                                                 Corporate     Trust-wide    Ron Moody                                       4      3     12   inspection audits). To include        Departments.
           compliance                                                                 Governance                                                                                    systems for control of contractors.

                                              Minimise accidental injuries to staff                                               Health and Safety Training                        Training; Incident Monitoring         Risk              HSE
           Staff injuries -                                                                         Directorate                   and Procedures                                                                          Assessments
LAM9                              H&S                                                 Lambeth                     Maresa Ness                                     4      3     12                                         undertaken in all
           Lambeth                                                                                  wide
                                                                                                                                                                                                                          areas.

                                              Health and Safety issues                                                            Lone worker guidance                              Health and Safety Rep to              To be reviewed    HSE
           Staff safety -                     at Westways. Safety of COAST staff Croydon                                                                                            review all H&S issues at              by Directorate
CRO5                              H&S         out of hours                                          Croydon       Tony Goss                                       4      3     12   Westways and submit proposals         H&S lead
           Croydon                                                               AMH

                                              Policy for transporting patients in                                                 Clinical Risk Assessment;                         Ratified November 2002                Ratified &        HSE
           Transporting                       private cars                                                                        Policy published                                                                        published on
TPR22                             H&S                                                 All           Trust-wide    Ron Moody                                       4      3     12                                         Trust Intranet
           patients policy (19)

                                              No contract in place for maintenance                                                Risk assessments                                  Written to Roy Jaggon requesting a None at present HSE
           York Clinic -                      work with Guys                                                                      completed. Risks identified                       Service Level Agreement with Guys
SOU5                              H&S                                                 Southwark     York Clinic   Isobel Morris                                   3      4     12   to be agreed.
           maintenance




            * See Key attached                                                                                           Page 6 of 13                                                                     06/12/2002                APPENDIX A
            SOUTH LONDON AND MAUDSLEY NHS TRUST                                                                      DRAFT RISK REGISTER




Number/
Source *                                                                                                                                                           Impact Likeli- =                                         Current            Independent
           Risk Name              Risk Type     Description/Objective                    Directorate    Location     Risk Owner      Existing Controls               x    hood Rating Action Plan                           Progress           Assurance
                                                Equipment in need of replacement to                                                                                                    Obtain quotes and seek guidance      Quotes recd,    MDA
           Equipment -                          maintain service standards          Specialist          Bethlem,                                                                       from Specialist Directorate          awaiting
SPEC16                            Operational                                                                        Brian Smith                                     4      4     16   Business Unit on bidding process     guidance on
           Pathology                                                                (Pathology)         Maudsley
                                                                                                                                                                                                                            bidding process

                                                To ensure Virus Protection                                                           No action plan required                           Anti Virus Software and Anti Virus   Virus protection Internal Audit
           P.C./Server Virus                                                                            ICT          Ricky                                                             Training and Awareness for Staff     is a high cost
ICT17                             Operational                                            ICT                                                                         4      4     16                                        activity
           (BS7.11)                                                                                     Department   Mackennon

                                                Adequate elimination of pests,                                                       Contracts with pest control                       Development of Pest Control policy; Clarify with E&F PEAT
                                                vermin, etc. to avoid future ward                                                    companies                                         Emergency arrangements;
INFC6      Pest control           Operational   closures                                 Trust-wide     All          Roy Jaggon                                      4      4     16   Effective monitoring


                                                Lease on current BIAS site expires                                                                                                     Project Officer in place. PCT      Project Board        Internal Audit
                                                August 2003                              Specialist                                                                                    agreement to support revenue cost. will review
SPEC13     Premises - BIAS        Operational                                                           BIAS         Marilyn Major                                   4      4     16                                      January. New
                                                                                         (Addictions)
                                                                                                                                                                                                                          site identified.

                                                Lack of Patient Transport Services                                                   Various alternative modes                         Contact Trust wide Transport group To be raised at Internal Audit
                                                and use of costly inappropriate taxis Croydon           Croydon and                  of transport used                                 to examine options for PTS.        Transport group
CRO12      Transport - Croydon Operational                                                                          Roy Jaggon                                       4      4     16                                      meeting.
                                                                                      AMH               Trust wide

                                                To achieve National standards for                                                    National standards; audit                         Ongoing monitoring                   Cleanliness        PEAT
                                                cleanliness (star rating)                Finance &                                   forms                                                                                  Group formed       Inspection
EF16       Cleanliness            Operational                                            Corporate      Trust-wide   Roy Jaggon                                      3      5     15                                                           Team
                                                                                         Governance

                                                Implement procedures to minimise                        All                          Trust and Local                                   Install automated alarms. Liaison    Negotiations       Fire Safety
           Fire - Night time fire               risks of night time fires in unstaffed                                               Procedures                                        with Fire Brigade                    with Housing       Audit
                                                                                                        Supported
LAM6       risk in unstaffed      Operational   Supported Housing                        Lambeth                     Maresa Ness                                     5      3     15                                        Ass and Fire
                                                                                                        accomm-
           supported housing                                                                                                                                                                                                Brigade.
                                                                                                        odation
                                                Reduce impact on clients/ staff of                                                   Min refurb whilst occupied;                       Decant facilities required           Decant facilities CHI
                                                undertaking building works on            Finance &                                   change client mix to                                                                   being identified
           Refurbishment of
CAP7                              Operational   occupied wards                           Corporate      Trust-wide   Roy Jaggon      achieve single-sex wards        3      5     15
           occupied wards
                                                                                         Governance                                  without need for major
                                                                                                                                     works
                                                Deliver service to client group                         North                        None currently                                    Being taken forward by Trustwide     Being taken     Internal Audit
           Transport for                        without additional drain on financial                   Lambeth &                                                                      transport group                      forward by
                                                                                         Lambeth /
LAM4       London Congestion Operational        resources or service disruption due                     Southwark    Pam Wastell                                     3      5     15                                        Trustwide group
                                                                                         Southwark
           Charges                              to Congestion Charging                                  catchment
                                                                                                        areas
                                                Insufficient site management cover                                                   On-call engineers                                 To review and increase night site    Discussions
           Bethlem - night site                 for BRH at night                         Croydon        Croydon and                                                                    management at BRH site               ongoing
CRO2                              Operational                                                                       Roy Jaggon                                       4      3     12
           E&F management                                                                AMH            Trust wide

                                                Inadequate decant facilities for                                                     Emergency contingency                             Convene Steering Group to            Croydon Project
                                                inpatient areas in the                                                               plans                                             produce MIP and decant plan          manager has
CRO7       Decant facilities      Operational   event of major building                  All            Trust-wide   Roy Jaggon                                      4      3     12                                        asked to be part
                                                works, fire etc.                                                                                                                                                            of MIP Group

                                                To ensure desktop resilience and                                                     Action Plan                                       Lockdown desktops; audit of           Progress with     Internal Audit
           Desktop                              protection                                                                                                                             physical security in high risk areas; Asset
                                                                                                        ICT          Ricky
ICT16      Maintenance            Operational                                            ICT                                                                         4      3     12   password protection of screen         Registration
                                                                                                        Department   Mackennon
           (BS7.10)                                                                                                                                                                    savers, desk top time out




            * See Key attached                                                                                              Page 7 of 13                                                                      06/12/2002             APPENDIX A
            SOUTH LONDON AND MAUDSLEY NHS TRUST                                                                  DRAFT RISK REGISTER




Number/
Source *                                                                                                                                                       Impact Likeli- =                                       Current            Independent
           Risk Name            Risk Type     Description/Objective                  Directorate   Location      Risk Owner      Existing Controls               x    hood Rating Action Plan                         Progress           Assurance
                                              Continuity Plans for all Critical                                                  Action Plan                                       Produce ISSPs, Disaster Recovery Not known            Internal Audit
           IT Continuation Plan               Systems                                              ICT           Ricky                                                             Contract, Test Environments, Stand
ICT7                            Operational                                          ICT                                                                         3      4     12   in Servers,
           (CA63/BS7.1)                                                                            Department    Mackennon

                                              Redesign physical environment and                                                  Existing Ladywell reception                       Application made for capital       Revenue funding Internal Audit
                                              layout of reception area on ground                                                                                                   funding.                           allocated,
           Ladywell Unit -
LEW11                           Operational   floor, Ladywell Unit to control access Lewisham      Ladywell Unit Tracey Power                                    3      4     12                                      awaiting capital
           physical security
                                              to the unit.                                                                                                                                                            funding.

                                              The ward upgrades are essential to                                                 Project management                                Specification being developed.     Behind             Internal Audit
           Ladywell Unit - ward               meet reasonable standards of                                                       arrangements are in place                                                            schedule.
LEW4                            Operational   patient care                           Lewisham      Ladywell Unit Tracey Power                                    4      3     12
           upgrades

                                              The response time to urgent                                                                                                          Meet with Facilities to agree      Raised at          Internal Audit
           Maintenance -                      maintenance issues                     Croydon                                                                                       minimum response times for all     corporate
CRO9                            Operational                                                        Croydon       Roy Jaggon                                      4      3     12   urgent maintenance requests        departments
           Croydon                                                                   AMH
                                                                                                                                                                                                                      event

                                              To ensure network protection and                                                   Action Plan                                       Ensure network documentation,      VEGA report        Internal Audit
           Network                            resilience                                                                                                                           resilience, decommissioning        completed
                                                                                                   ICT           Ricky
ICT14      Maintenance          Operational                                          ICT                                                                         4      3     12   procedures, Change Control in line
                                                                                                   Department    Mackennon
           (BS7.8)                                                                                                                                                                 with VEGA Infrastructure Work

                                              To ensure physical and                                                             Action Plan                                       To ensure protection from Theft,   No. of incidents   Internal Audit
           Physical                           environmental protection to ICT                                                                                                      Fraud, Humidity, High              re physical
                                                                                                   ICT           Ricky
ICT15      Environment          Operational   Equipment                              ICT                                                                         3      4     12   Temperatures, Fire, Flood          security and
                                                                                                   Department    Mackennon
           Protection (BS7.9)                                                                                                                                                                                         env. Protection

                                              Full and up to date documentation of                                               Action Plan                                       Fully documented procedures,       Progress is        Internal Audit
           Systems and                        all major Trust Systems                                                                                                              Operator Logs, Change Control      patchy
           Servers                                                                                 ICT           Ricky                                                             with Audit Trails, Decommissioning
ICT8                            Operational                                          ICT                                                                         4      3     12
           Maintenance                                                                             Department    Mackennon                                                         old software/hardware, time out of
           (BS7.2)                                                                                                                                                                 applications
                                              Poor door security system main                                                     GSTT Security staff                               Meeting with David James re                           Internal Audit
           York Clinic -                      entrance and atrium                                                                                                                  security. Meeting with Guys
SOU13                           Operational                                          Southwark     York Clinic   Isobel Morris                                   3      4     12   Facilities Manager - November
           Security




            * See Key attached                                                                                          Page 8 of 13                                                                     06/12/2002            APPENDIX A
            SOUTH LONDON AND MAUDSLEY NHS TRUST                                                                      DRAFT RISK REGISTER




Number/
Source *                                                                                                                                                              Impact Likeli- =                                            Current             Independent
           Risk Name             Risk Type         Description/Objective                 Directorate    Location     Risk Owner        Existing Controls                x    hood Rating Action Plan                              Progress            Assurance
           Building Contractors                To eliminate complications &                                                            Policy in place for Lambeth.                       To develop policies and procedures Addressed via  HSE/ Internal
                                               unbudgeted costs arising from             Finance &                                     Some compliance to                                 Trust-wide                         E&F Stat       Audit
           - Control of
EF3                             Organisational contractors working on Trust sites        Corporate      Trust-wide   Barry Huckstep    procedures elsewhere.            5      4     20                                      Compliance
           Contracts &
                                                                                         Governance                                                                                                                          Working Group.
           Contractors
                                                To eliminate multiple breaches of                                                      H&S statutory compliance                           Currently no detailed Action Plan to    Review          EHO
                                                statutory waste management               Finance and                                   checks. Review by E&F                              implement waste management              undertaken; Env inspections /
           Environment -
EF24                             Organisational requirements                             Corporate      Trust-wide   Roy Jaggon        Management.                      4      5     20   procedures which address statutory      Policy being    HSE
           Operational Waste
                                                                                         Governance                                                                                       requirement failure                     developed

                                                   Manage increased risks caused by                                                    Fire Safety Policy; Fire                           Cont. plan includes: checking local     Contingency         HSE/ Fire
                                                   FBU strike action                                                                   Safety Audits; Contingency                         procedures & evacuation drills;         plans in place      Safety
           Fire - Fire Brigade                                                                                                         plans                                              additional fire training; advice and                        Auditors
CG1                              Organisational                                          Trust-wide     Trust-wide   Cliff Bean                                         5      4     20
           Union strikes                                                                                                                                                                  guidance to staff; extra Estates &
                                                                                                                                                                                          Facilities cover
                                                   Fire Safety. Improve attendance at                                                  50% attendance                                     Introduce use of networked DIY fire     More training       Contracted
                                                   fire training [16]                                                                  anticipated 2002/3                                 safety training and tests; training     provided;           Fire Safety
CA33       Fire Safety - training Organisational                                         Trust-wide     Trust-wide   Barry Huckstep                                     4      5     20   opportunities have been increased       expecting 60%       auditors
                                                                                                                                                                                          this year                               increase on last
                                                                                                                                                                                                                                  year
                                                Buildings, Land, Plant, and Non-                                                       Statutory compliance                               Consolidate operational estates         Plan in             EHO
           Buildings -                          Medical Equipment. Compliance with Finance &                                           audits.                                            policies and procedures. Establish      development         inspections;
CA3                              Organisational statutory requirements[4,11]       Corporate            Trust-wide   Roy Jaggon                                         4      4     16   systems of safe working and
           compliance
                                                                                   Governance                                                                                             controls which meet requirements.

                                                   Inadequate systems for managing                                                     Reviewed by                                        Define board level responsibility for   Environmental       EHO
                                                   environmental risks                   Finance and                                   Environmental                                      environmental strategy; adopt           Policy being
           Environment -                                                                                                               management consultant                              recognised environmental                developed for
EF17                             Organisational                                          Corporate      Trust-wide   Barry Huckstep                                     4      4     16
           Management                                                                                                                                                                     management system; communicate          Board approval
                                                                                         Governance
                                                                                                                                                                                          responsibilities to all levels.
                                                Uncontrolled discharge of                                                              Reviewed by                                        Implement rigorous operational          Environmental       EHO
                                                substances to air land and water         Finance and                                   Environmental                                      control of waste, chemicals and oil.    Policy being
           Environment -
EF23                             Organisational potentially leading to legal             Corporate      Trust-wide   Barry Huckstep    management consultant            4      4     16                                           developed for
           Pollution                            proceedings and costly remedial                                                                                                                                                   Board approval
                                                                                         Governance
                                                works
                                                Uncontrolled traffic growth leading to                                                 Reviewed by                                        Set up partnerships with the local      Environmental       EHO
                                                failure to meet the expectations of      Finance and                                   Environmental                                      authority Agenda 21group,               Policy being
           Environment -
EF19                             Organisational stakeholders.                            Corporate      Trust-wide   Roy Jaggon        management consultant            4      4     16   transport providers, health             developed for
           Transport                                                                                                                                                                      promotion groups, residents and         Board approval
                                                                                         Governance
                                                                                                                                                                                          other stakeholders.
                                               Ensure that ICT incident reporting                                                      No action plan required                            Changes in practice are                 ICT Security        Internal Audit
           Incidents - Learning                results in re-occurrence prevention                                                                                                        implemented, recommendations            Committee set
ICT12      from ICT             Organisational                                           ICT            Trust-wide   Philip Robinson                                    4      4     16   from ICT Security Reports are           up
           incidents(BS7.6)                                                                                                                                                               implemented

                                                Security of Signpost unit to be                                                                                                           Service to be relocated                 Project Board       Internal Audit
                                                improved. Lack of space for clients      Specialist     Addictions                                                                                                                will be set up in
SPEC23     Security - Signpost   Organisational & staff                                                              Marilyn Major                                      4      4     16                                           January 2003.
                                                                                         (Addictions)   services

                                                   Policies & procedures in place to                                                   Systems in place                                   Introduction of Environmental           Environmental       EHO/ HSE
                                                   meet legislation                      Finance &                                                                                        Policy.                                 Policy being
EF4        Waste Management Organisational                                               Corporate      Trust-wide   Barry Huckstep                                     4      4     16                                           developed for
                                                                                         Governance                                                                                                                               Board approval




            * See Key attached                                                                                              Page 9 of 13                                                                         06/12/2002                 APPENDIX A
            SOUTH LONDON AND MAUDSLEY NHS TRUST                                                                        DRAFT RISK REGISTER




Number/
Source *                                                                                                                                                               Impact Likeli- =                                             Current           Independent
           Risk Name              Risk Type        Description/Objective                    Directorate   Location     Risk Owner      Existing Controls                 x    hood Rating Action Plan                               Progress          Assurance
           Clinical Records                      Closure of all supplementary clinical                                                 Project Plan                                        Large scale project covering many Not known                Internal Audit
           Management -                          records storage areas following the                                                                                                       different sites of the organisation.
ICT6       Retention,             Organisational implementation of the Retention       ICT                Trust-wide   Joan Naish                                        5      3     15
           Preservation and                      Preservation and Destruction Policy
           Destruction
                                              To ensure that the Trust can report                                                      Action Plan                                         Review information demands               No progress       Internal Audit
           Information Systems                on its clinical activities effectively and                                                                                                   against the information systems
                                                                                                          ICT
ICT18      may not report to   Organisational in line with DH requirements               ICT                           Mike Denis                                        3      5     15   that we have in place and take
                                                                                                          Department
           DH requirements                                                                                                                                                                 action accordingly

                                                   Risk Management. Completion of                                                      Review of processes and                             Close action planning                    Partially, review Internal Audit
                                                   risk management cycle [27]                                                          procedures by Risk                                  implementation and follow up loop.       of risk
           Risk Management -                                                                Finance &                                  Management Committee                                Identified risks, and effectiveness of   management
CA86       risk management   Organisational                                                 Corporate     Trust-wide   Cliff Bean                                        5      3     15   risk treatments to be monitored and      controls and
           cycle                                                                            Governance                                                                                     reviewed on a continuous basis.          actions rarely
                                                                                                                                                                                                                                    completed.
                                                 Security measures to be completed,                                                    Reception desk                                      Proceed with agreed action -             Installation
           Security -                            inc. Reception desk entry swipe                                                                                                           installation of Security Access          complete.
SOU16      Outpatients,           Organisational cards.                             Southwark             Maudsley     Isobel Morris                                     3      5     15   system                                   Procedure for
           Maudsley                                                                                                                                                                                                                 use being
                                                                                                                                                                                                                                    negotiated.
                                                   All significant risks in E&F function                                               Some internal work has                              E&F Managers to feed in risks       Project                Internal Audit
                                                   should be fed into risk register [8]     Finance &                                  been done on departmental                           identified through formal and adhoc underway
           Buildings - Risk
CA4                               Organisational                                            Corporate     Trust-wide   Roy Jaggon      risks and statutory               4      3     12   risk identification.
           Management
                                                                                            Governance                                 compliance.

                                                   Infection Control Team notification of                                              Infection Control involved in                       Develop checklist to ensure ICT          Clarify with     CNST
           Buildings - Trust                       new projects and refurbishments                                                     some planning groups                                involvement                              Capital Planning
INFC9      new builds/            Organisational                                            Trust-wide    All          Roy Jaggon                                        3      4     12
           refurbishments

                                                 A detailed action plan has been                                                       Clinical Governance                                 Detailed Action plan to be               Action plan      CHI/ StHA's
                                                 produced following the 2002 review                                                    structures in place                                 implemented                              approved by
           CHI action plan
CG3                               Organisational and recommendations by the         All                   Trust-wide   David Roy                                         4      3     12                                            StHA's; being
           implementation                        Commission for Health Improvement                                                                                                                                                  taken forward by
                                                                                                                                                                                                                                    committees

           Clinical Records                        Clinical Records Transfer                                                           Action Plan                                         Implement safe bags, develop          Not known            CNST
           Management -                                                                                                                                                                    procedure for the operation of safe
ICT5       Transfer of Clinical   Organisational                                            ICT           Trust-wide   Joan Naish                                        4      3     12   bags and audit trail for records
           Records within the                                                                                                                                                              moving internally within organisation
           Trust
                                                 Inefficient and unsustainable use of                                                  Consultants have reviewed                           Implement an energy efficiency           Environmental     Internal Audit
                                                 energy resulting in a major waste of       Finance and                                system                                              programme and source energy              Policy being
           Environment -
EF18                              Organisational resources and irreversible harm to         Corporate     Trust-wide   Roy Jaggon                                        3      4     12   supplies from renewable sources.         developed for
           Energy
                                                 the environment                            Governance                                                                                                                              Board approval

                                             No planned arrangements for land                                                          Consultants have reviewed                           Improve Trust environmental              Environmental     Internal Audit
                                             take and habitat management,                   Finance and                                system                                              performance to minimise effects on       Policy being
           Environment - Land
EF22                          Organisational leading to loss of habitats and                Corporate     Trust-wide   Roy Jaggon                                        4      3     12   sites. Identify and record               developed for
           use and Ecology
                                             irreversible ecological damage                 Governance                                                                                     environmental risks using Trust risk     Board approval
                                                                                                                                                                                           management methodology
                                                 No environmental procedures in                                                        Consultants have reviewed                           Incorporate environmental criteria       Environmental     Internal Audit
                                                 Trust procurement procedures               Finance and                                system                                              into all contracts where legitimate.     Policy being
           Environment -                                                                                                                                                                   Ensure “green” issues included in
EF21                              Organisational enables untrained staff to buy             Corporate     Trust-wide   Roy Jaggon                                        4      3     12                                            developed for
           Materials                             environmentally damaging or illegal                                                                                                       life cycle costing of all investments.   Board approval
                                                                                            Governance
                                                 products                                                                                                                                  Env. surveys of local suppliers




            * See Key attached                                                                                               Page 10 of 13                                                                        06/12/2002                 APPENDIX A
            SOUTH LONDON AND MAUDSLEY NHS TRUST                                                                       DRAFT RISK REGISTER




Number/
Source *                                                                                                                                                         Impact Likeli- =                                        Current          Independent
           Risk Name               Risk Type        Description/Objective                Directorate     Location     Risk Owner     Existing Controls             x    hood Rating Action Plan                          Progress         Assurance
                                                  Reactive approach to water                                                         Consultants have reviewed                       Review water use and cost           Environmental    Internal Audit
                                                  management leading to moderate         Finance and                                 system                                                                              Policy being
           Environment -
EF20                               Organisational waste of resources                     Corporate       Trust-wide   Roy Jaggon                                   3      4     12                                       developed for
           Water
                                                                                         Governance                                                                                                                      Board approval

                                                    Infection Control. Adequate infection                                                                                            Develop infection surveillance      Work started     CNST
           Infection Control -                      surveillance policy [9]                                                                                                          policy.
                                                                                          All Clinical
CA59       infection               Organisational                                                        Trust-wide   Karen Taylor                                 3      4     12
                                                                                          Directorates
           surveillance policy

                                                  Approved security policy and                                                       Partial compliance                              Services review; progress budget;   Not known        RPST
           Security - in-patient                  strategic implementation of in-patient Finance &                                                                                   develop & implement local policy
EF6                                Organisational site risk assessments                  Corporate       Trust-wide   Roy Jaggon                                   4      3     12
           sites
                                                                                         Governance

                                                    Community sites vulnerable                                                       Monitored at local and                          Recommendations made for site       No funds this    RPST
           Security - MHOA                                                                                                           senior management level                         cameras and panic buttons - no      year
MHOA9                              Organisational                                        MHOA            MHOA         David Norman                                 4      3     12   funding available
           community sites

                                              Lack of local managerial                                                               Finance Manual                                  To examine options for key          None             Internal Audit
           Support Directorate                responsibility for Training and                                                                                                        members of support staff to be
                                                                                         Croydon         Croydon and
CRO15      accountability -    Organisational Information Managers                                                   Tim Greenwood                                 3      4     12   managed in Service Directorates
                                                                                         AMH             Trust wide
           Croydon




            * See Key attached                                                                                              Page 11 of 13                                                                  06/12/2002             APPENDIX A
            SOUTH LONDON AND MAUDSLEY NHS TRUST                                                                   DRAFT RISK REGISTER




Number/
Source *                                                                                                                                                           Impact Likeli- =                                        Current            Independent
           Risk Name              Risk Type   Description/Objective                  Directorate     Location     Risk Owner          Existing Controls              x    hood Rating Action Plan                          Progress           Assurance
           Information                        ICT Awareness Training to a suitable                                                    Action Plan                                      Develop and deliver needs           IT Security
           Governance / ICT                   level for all Staff                                                 Araripe                                                              assessed training programme -       Training Matrix
ICT9                         Staff                                                   ICT             Trust-wide                                                      4      4     16   utilising a variety of methods      being developed
           Security -                                                                                             Garboggini
           Awareness (BS7.3)                                                                                                                                                           including Trust Intranet

                                              Resolve recruitment & retention                                                         Agency radiographer                              Working with King's R&R initiatives - Draft paper
                                              difficulties                           Specialist                                       employed but high cost and                       new pay and conditions framework ready, aim to
           Recruitment -                                                                             Neuro-
SPEC26                            Staff                                              (Neuro-                      Gay Coombes         low skills                     3      5     15   linked to competencies.               implement by
           Neuroimaging                                                                              Imaging
                                                                                     Imaging)                                                                                                                                April 2003.

                                              Inadequate monitoring due to lack of                                                    Local statistics kept by                         Part of the HR/Pay integration      Not known
           Absenteeism                        management information                                                                  some units                                       project
                                                                                                                  Sally Dibben/
SCA12      through sickness -     Staff                                              HR              Trust-wide                                                      3      4     12
                                                                                                                  Mike Kelly
           lack of control over

                                              Use of agency on wards                                                                  Bor.Mgs only to agree                            Skill mix review to be undertaken   Awaiting report
           Agency usage -                                                                            All MHOA                         agency use. No overtime                                                              on skill mix
MHOA3                             Staff                                              MHOA                         David Norman        allowed.                       3      4     12                                       review
           MHOA                                                                                      wards

                                              Recruitment Process,                                                                                                                     Meet with HR to discuss the         Corporate
           Recruitment -                      Staff Bank                             Croydon                      Sally Dibben/                                                        recruitment process being driven    departments day
CRO8                              Staff                                                              Croydon                                                         3      4     12   and led locally                     held. Issues
           Croydon                                                                   AMH                          Mike Kelly
                                                                                                                                                                                                                           raised at event

                                              Difficulties in attracting appropriately                                                                                                 London-wide group is looking into   Not known
           Recruitment -                      trained staff - risks to service         Specialist                                                                                      this.
SPEC17                            Staff       provision and increased stress on                      Pathology    Brian Smith                                        4      3     12
           Pathology                                                                   (Pathology)
                                              existing staff

                                              The Directorate has a problem with                                                      Recruitment plan in place                        Human resources plan being          Campaign
           Recruitment and                    vacancies and associated agency                        Borough                                                                           produced                            recruitment;
LEW7       retention -            Staff       and bank situation                     Lewisham        wide - mainly Tracey Power                                      3      4     12                                       improvements to
           Lewisham                                                                                  Ladywell Unit                                                                                                         recruitment
                                                                                                                                                                                                                           process
                                              The Directorate has vacancies and                                                       Recruitment plan                                 Medical staffing. Human Resource    Monthly
           Recruitment and                    associated issues in relation to using                                                                                                   work. Recruitment drives. Plan to   meetings and
                                                                                                     Borough
SOU4       retention -            Staff       bank staff as opposed to agency        Southwark                    Isobel Morris                                      3      4     12   reduce usage agency. Work with      progress against
                                                                                                     wide
           Southwark                          staff                                                                                                                                    nurse bank                          plan

           Staffing levels -                  Possibility of establishments not                                                       Budgets based on                                 Exercise to emphasise reporting     Not known
           inappropriate to                   assessed for current operational                                    Sally Dibben/       historical data                                  data to benchmark performance.
SCA3                              Staff       needs                                  HR              Trust-wide                                                      4      3     12
           meet operational                                                                                       Mike Kelly
           requirements
                                              Not aware of training delivered or                                                                                                       Agreed this will be looked into.    Not known
                                              outstanding training needs of
SCA5       Training - records     Staff       individuals. Lack of training records/ Training        Trust-wide   Hillary McCallion                                  3      4     12
                                              management information reporting
                                              system.




            * See Key attached                                                                                          Page 12 of 13                                                                         06/12/2002            APPENDIX A
               SOUTH LONDON & MAUDSLEY NHS TRUST RISK REGISTER

Author         A Hogwood
Version        4.5
Date           6th December 2002

KEY TO CODES

Code           Source
CA             Controls Assurance
CAMHS          Child & Adolescent
CAP            Capital Plan
CG             Corporate Governance
CL             Clinical
CLA            Claims
COM            Communications & Publicity
CRO            Croydon
EF             Estates & Facilities
FIN            Finance
HR             Human Resources
HS             Health & Safety
ICT            Information & Communication Technology
INC            Incident Reports
INFC           Infection Control
LAM            Lambeth
LEW            Lewisham
MHOA           Older Adults
NURS           Nursing
OT             Occupational Therapy
PSYC           Psychology
SCA            South Coast Audit
SOU            Southwark
SPEC           Specialist
TP             Trust Clinical Policies (unratified)
TPR            Trust Clinical Policies (ratified)




Key                                                              APPENDIX A

								
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