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					                                                                                                                                  RISK REGISTER
                                                          Source of       Consequence                Current Risk  Previous   Residual                                                                                                         Date of    (Corporate)
Risk Reference               Description                                                Likelihood                                                       Controls                        Summary Risk Treatment Plan (Corporate)                                          (Corporate) Risk Owner
                                                            Risk               s                        Score     Risk Score Risk rating                                                                                                       Review    Action Owners

                 Healthcare for All – A failure to                                                                                         POLICY: Healthcare For All            Inpatient audit sent to clinical audit. Community audit
                 meet DoH targets set by their paper                                                                                       OVERSIGHT: Board / LD Board           passed to LD Governance Committee.
                 “Valuing People” relating to Health                                                                                       MONITORING: Health Facilitator in     Training on HAP, Traffic light Assessments, tackling
                 Action Plans, Health Facilitators                                                                                         post Audits / Training/ Team Visits   health inequalities. Ongoing across county.
                 and GP registration for service
                                                                                                                                                                                 Plans to deliver training on HAP’s to Primary Health Care
                 users may result in poor service                                                                                                                                on ‘reasonable adjustments’
   C-01/08       and regulatory breach which will                           Fatality     Possible         12                       8                                             2 LD Hospital Liaison Nurses start induction on 16.11.09.     Q3/09     Mark Scheepers        S Thompson
                 adversely affect the Trust’s           2008/09                                                                                                                  To be based in Riverside House (CGH)
                 reputation.                                                                                                                                                     72 GP practices signed SLA with PCT to undertake annual
                                                                                                                                                                                 health checks. 12 not signed. (S.Shorrick – Nov09)

                 CLINICAL GOVERNANCE –                                                                                                     POLICY: NHSLA Standards / NICE        Clinical Governance Strategy in process of being updated
                 Failure to operate effective clinical                                                                                     guidelines / CPA Policy/Recruitment   in readiness for April 2010.
                 governance arrangements may                                                                                               Clinical Effectiveness Strategy       Paul Ryder seconded on 6 month basis from Oct 09-Mar 10
                 result in;                                                                                                                OVERSIGHT;                            to assist with the SUI process/project work and increase
                 • serious untoward incidents)                                                                                                                                   capacity within the department to meet demand . PWC
                 • loss of reputation                                                                                                                                            have undertaken an internal audit of all Governance
   C-03/08       regulatory / legal breach                                  Serious       Certain         10                       8                                             systems, the results of which will lead to action planning.   Q3/09     Gordon Benson       P Winterbottom
                                                            2008/09                                                                                                              Capacity remains an issue and it is anticipated that the
                                                                                                                                                                                 SUI/Project Manager post will become substantive to
                                                                                                                                                                                 continue to support clinical governance functions (G
                                                                                                                                                                                 Benson Jan 2010)

                 ACI (Acetylcholinesterase Inhibitor)                                                                                      POLICY: National Dementia Strategy    Shared Care Agreement in draft for D&Tc. To support
                 MONITORING - –                                                                                                            is WIP. Dementia Commissioning        work of Primary Care Developments for Community
                 The current shared care agreement                                                                                         Group. Service specifications         Dementia Nursing. Caseload capacity being considered in
                 requires reviewing to ensure that                                                                                         developed. OVERSIGHT (OPS):           respect of new memory clinic service- i.e. establishing a
                 requirements for TA111 are met.             Risk                                                                          Standard Reporting (within NICE
                                                                                                                                                                                 Dementia Maintenance role in each team to support                                           R Alstead & Paul
                                                                                                                                           Guidelines) by teams in place
   C-04/08                                                                  Serious       Certain         10                       8                                             broader follow up including ACI monitoring (pending           Q3/09      Tim Coupland
                                                          Workshops                                                                                                                                                                                                           Winterbottom
                                                            2008/09                                                                                                              commissioning of Community Dementia Nursing). Service
                                                                                                                                                                                 Spec awaiting contracting decision in Feb
                                                                                                                                                                                 2010.(T.Coupland Jan 10)

                 SOCIAL INCLUSION – A failure to                                                                                           POLICY:Mental Health Act/Equal        The goal of socially inclusive practice remains of pivotal
                 meet legal/regulatory and                                                                                                 Opportunities/Mental Capacity Act     importance in the development and delivery of the Trusts
                 organisational commitment to                                                                                              OVERSIGHT: Board / Inclusion &        business. Several key milestones have been recently
                 social inclusion may result in poor                                                                                       Diversity Cttee (LD)                  achieved including the development and launch of
                 service experienced by service                                                                                            MONITORING:(WI) by I & D Cttee
                                                                                                                                                                                 Gloucestershire’s Multiagency Social Inclusion Strategy.
                 users and adversely affect the                                                                                                                                  The strategy gained a high profile at the Social Inclusion
                 Trust’s reputation thereby                                                                                                                                      conference event ‘Making Life Better’ in October 2009.
                 potentially impacting on the future                                                                                                                             During the summer of 2009 a Social Inclusion Social
                 commissioning of services                                                                                                                                       Marketing campaign across Gloucestershire was
                                                             Risk                                                                                                                undertaken. Further details of the wide participation
   C-10/08                                                                  Serious      Unlikely         9            4                                                         achieved from members of Trust staff, Governors, partner      Q3/09      Jane Melton          Shaun Clee
                                                                                                                                                                                 organisations, the media and the public can be found on
                                                                                                                                                                                 the following website.
                                                                                                                                                                                 Future plans are being set though the SSU business
                                                                                                                                                                                 planning process and the Multiagency Social Inclusion
                                                                                                                                                                                 Action Planning Forum which is overseen by the Social
                                                                                                                                                                                 Inclusion Executive for Gloucestershire. One of the key
                                                                                                                                                                                 areas for consideration is further training for staff about
                                                                                                                                                                                 socially inclusive practice. (J.Melton Nov09)
          CPA - Failure of staff to comply                                                           POLICY: Policy & Procedures for Care A new CPA care management Quality assurance Officer in
          with the Trust’s CPA policy could                                                          Coordinatiion.OVERSIGHT: Board       place. Individual team audits have commenced and Trust-
          lead to a serious untoward incident.                                                       reports IPR. Caseload                wide programme is being implemented. (J.Hill July 09)
                                                   Risk                                              Supervision/Case notes /Self audit.
          A systemic compliance failure
                                               Identification                                        TRAINING: Registers / certificates.
C-02/08   would mean a breach which would                         Major     Possible    9   12   6                                                                                                         Q3/09          J Hill          S.Thompson
          need to be reported to the              2008/09

          MEDICINES MANAGEMENT – – If                                                                POLICY: Policy on Ordering,            New NMP lead in post who will now take a lead on this -
          there is a failure to provide safe                                                         Prescribing and Administration of      Helen Elliot (T.Coupland - July09)
          systems of working with medication                                                         Medicines (P.O.P.A.M)./ SLA in place.
          may lead to a serious untoward         Risk                                                POPAM Protocols & Guidance/ NICE.
          incident.                          Identification                                          OVERSIGHT: Drugs & Therapeutics                                                                               Juliette Shepherd &     R Alstead &
C-05/08                                                           Major     Possible    9        6   Committee (Dr. Ardagh - Chair) /                                                                      Q3/09
                                                 Workshops                                                                                                                                                             T.Coupland        P.Winterbottom
                                                  2008/09                                            Pharmacist in post (not employed by
                                                                                                     trust) MONITORING: Medicine Errors
                                                                                                     Reporting System. TRAINING:
                                                                                                     Certificate in Non-medical Prescribing

          INFECTION CONTROL - Failure to                                                             POLICY: Trust Hygiene Code.             We continue to work with NHS Gloucestershire on a
          put in place effective infection                                                           OVERSIGHT: Director of Infection        county wide response and have a pandemic flu plan in
          prevention and control strategy                                                            Prevention & Control Phillipa Moore -   place (V.Tweddle July 09)
          embedded within the Trust could                                                            consultant - Quarterly/annual Reports
C-07/08   affect the safety of patients                          Fatality    Unlikely   8        4   (Board). Infection Control Focus group.                                                               Q3/09       L Forrester         R Alstead
                                                                                                     Annual Audit.OPERATIONS:Infection
                                                                                                     Control Team / Cleaning Services.
                                                                                                     TRAINING: mandatory training

          DTOC - An ineffective                                                                      POLICY: Direction on Choice of          Overall score for Trust is currently below 7.5%. Escalation
          discharge/transfer process will lead                                                       Accommodation”. OVERSIGHT:              process in place - monitored through regular performance
          to delayed transfer of care                                                                Performance dashboard/Weekly            reporting (S.Thompson July 09)
          (DTOCs) which can have a serious Identification                                            reports (information dept)/ Operational
C-06/08   adverse affect on the wellbeing of                     Serious      Likely    8        6   Management Committee                                                                                  Q3/09     S Thompson           S Thompson
          the service user. In addition,                                                             Multi-Agency Working Group
          increasing numbers of DTOCs will
          impact upon the Trust’s bed
          capacity and could breach
          MEDICAL COVER - If there is a                                                              POLICY: Staffing Establishment       Staffing requirements are managed through SSU Boards
          failure to provide adequate medical       Risk                                             Procedure / Job descriptions         with gaps escalated to Chief Operating Officer. Work in
          cover then this adversely affects the Identification                                       OVERSIGHT: Operations Management     hand to look at overall Workforce Plan for
C-08/08   ability to deliver care.                               SERIOUS     LIKELY     8        6   Committee / Consultants Meeting                                                                       Q3/09      Martin Ansell       S Thompson
                                                 Workshops                                                                                future.(S.Thompson July 09)
                                                                                                     (fortnightly) MONITORING: Budgets

          WAITING TIMES - Failure to meet                                                            POLICY:Trust set targets.            Overall performance by Trust is achieving 80% within 6
          the Trust’s target of seeing a                                                             OVERSIGHT: Board reports - IPR.      weeks Trust target. Managed through Integrated
          service user within 6 weeks of an                                                          Monthly review by OPS.               Performance reporting.(S.Thompson July09)
          initial referral which if not met
          consistently may impact on the
          Trust’s reputation and ability to
          compete for services.

C-09/08                                                          SERIOUS    POSSIBLE    6        4                                                                                                         Q3/09     S Thompson           S Thompson

                                                          Source of       Consequence                Current Risk  Previous   Residual                                                                                                         Date of    (Corporate)
Risk Reference               Description                                                Likelihood                                                      Controls                        Summary Risk Treatment Plan (Corporate)                                          (Corporate) Risk Owner
                                                            Risk               s                        Score     Risk Score Risk rating                                                                                                       Review    Action Owners

                 CONTRACT INCOME - The                                                                                                     POLICY: Contract (12 month notice    To mitigate against this risk, we have now signed a new
                 Primary Care Trust may serve                Risk                                                                          period0 OVERSIGHT: Service Quality   contract which is in place until March 2010. We have now
                 notice on part of our contract to       Identification                                                                    Monitoring Groups MONITORING:        also received a letter providing re-assurance that it is the
   F-01/08                                                                   Major        Likely          12                       9                                                                                                           Q3/09        S.Betney           S.Betney
                 provide services which will result in    Workshops                                                                        Contract Monitoring Board            intention to commission with the Trust in the future.
                 a significant loss of income               2008/09
                                                                                                                                                                                (S.Betney - Nov09)
                 BACS SYSTEM (PAY) - A failure of                                                                                          POLICY: OVERSIGHT:Finance dept & Meeting set up in July with Senior Payroll staff to
                 the BACS system may result in a                                                                                           Shared Financial Services (Payroll) investigate options (T.Hartley July09)
                 failure to pay staff salaries on the       Risk                                                                           MONITORING:
                 due date may result in an adverse      Identification
   F-02/08                                                                   Major       Possible         9                        6                                                                                                           Q3/09        T.Hartley          S.Betney
                 affect on;                              Workshops
                 • staff morale                            2008/09
                 • financial loss
                 • reputation
                 INSURANCE – If Trust premises                                                                                             POLICY: OVERSIGHT: MONITORING: Full insurance review carried out. Report to Governance
                 are not fully insured then this may        Risk                                                                                                                Committee now planned for October 09 (D.McGrath
                 result in a significant financial loss Identification                                                                                                          July09))
   F-03/08       should a building be damaged due                            Major       Possible         9                        6                                                                                                           Q3/09       D.McGrath          D.McGrath
                 to fire/other event                       2008/09

                 COMMUNICATIONS (Financial) -                                                                                              POLICY:Annual Plan / timetable by    Meeting held recently to review 08/09 timetable and
                 A failure to produce & publish final                                                                                      Finance dept/Finance Director        outcomes so planning for 09/10 can be refined (T.Hartley
                 accounts within to agreed                                                                                                 of Corporate Affairs                 July09)
   F-04/08       deadlines, may result in;                                   Major       Possible         9                        6       OVERSIGHT: Sign off by Audit                                                                        Q3/09        T.Hartley          S.Betney
                 • Regulatory breach                                                                                                       Committee
                 • Reputational damage
                 DELEGATED AUTHORITY                                                                                                       POLICY: Standing Financial
                 (Standing Financial Instructions)–                                                                                        Instructions OVERSIGHT:Finance
                                                             Risk                                                                          Dept MONITORING:
                 Individuals acting outside of their
   F-05/08       delegated authority may result in a                        Serious       likely          8                        6                                                                                                           Q3/09        S.Betney           S.Betney
                 financial loss                             2008/09

                 COMMISSIONING/ TENDERING –                                                                                                POLICY: Business Development         ACTION: Policy being developed (WIP)
                 A failure to identify all potential                                                                                       Process OVERSIGHT: Business
                                                             Risk                                                                          Development Cttee MONITORING:
                 issues inherited within a service at
                                                         Identification                                                                    Executive Cttee
   F-06/08       bidding stage may result in                                Serious      Possible         6                        4                                                                                                           Q3/09        S Betney           S.Betney
                 reputational risk and/or financial         2008/09

                                                          Source of       Consequence                Current Risk  Previous   Residual                                                                                                        Date of    (Corporate)
Risk Reference               Description                                                Likelihood                                                       Controls                       Summary Risk Treatment Plan (Corporate)                                             (Corporate) Risk Owner
                                                            Risk               s                        Score     Risk Score Risk rating                                                                                                      Review    Action Owners

                 NICE GUIDELINES – A failure to                                                                                            POLICY: Implementing Best Practice   National Guidance Manager appointed in September 2009
                 adhere to NICE guidance may                                                                                               OVERSIGHT: Board Practice            (Judith Quartmaine). Policy for Implementation of NICE
                 result in a serious untoward incident                                                                                     Standards Committee                  Guidance revised and approved October 2009. Stocktake
                 or regulatory breach leading                                                                                              Operational Management Meeting (S    of available evidence completed and actions in place.
                                                             Risk                                                                          Thompson) SSU Boards
                 possible financial penalties.                                                                                                                                  Monitoring of implementation of NICE guidance is now
                                                         Identification                                                                    MONITORING                                                                                                                            R Alstead &
   G-10/08                                                                  Serious       Certain         10           8           6                                            undertaken at the Contract Board with NHS                     Q3/09         G.Benson
                                                          Workshops                                                                        Clinical Audit                                                                                                                      P.Winterbottom
                                                            2008/09                                                                                                             Gloucestershire, and is a standing agenda item on all SSU
                                                                                                                                                                                Governance Committees. PWC have completed an internal
                                                                                                                                                                                audit of systems and process which will lead to action
                                                                                                                                                                                planning where appropriate. (G Benson Jan 2010)

                 OMBUDSMAN COMPLAINTS                                                                                                      POLICY: CPA policy/ Suicide Strategy/ Action plan to mitigate risks from historic complaints are
                 (HISTORIC) – If the Trust has failed                                                                                      Recruitment policy                      in place as far as reasonably practicable (D.McGrath
                 to maintain high standards of care                                                                                        OVERSIGHT:Board/MARMAP/Complai July09).
                 in the past, then it may suffer          Risk                                                                             nt & litigation reports/
                 adverse consequences;                Identification                                                                       MONITORING:NHSLA Safety Notice
   G-01/08                                                                   Major       Possible         9            15         10                                                                                                          Q3/09          S.Clee                S.Clee
                 • Service User concern                Workshops                                                                           system / Child protection & adults at
                                                         2008/09                                                                           risk procedures /Supervision & training
                 • Financial loss
                                                                                                                                           / National Care Standards
                 • Reputation loss
                 • Regulatory breach
                 PERSONAL DATA SECURITY - A                                                                                                POLICY: IT Security /Data Policy/    Apira consultants IG audit report showed greatly improved
                 failure to ensure personal data is                                                                                        Protection OVERSIGHT:                understanding of IG issues amongst staff. Teams that
                                                            Risk                                                                           MONITORING:TRAINING:
                 kept secure will lead to a loss of the                                                                                                                         were audited have action plans which will be monitored.
   G-02/08       Trust’s reputation.                                         Major       Possible         9            12          8                                            Phase II of the encryption project for email                  Q3/09        S.O'Connell           S.Thompson
                                                           2008/09                                                                                                              underway.(S.O'Connell July 09)

                 MANAGEMENT OF                                                                                                             POLICY: EDS Contract OVERSIGHT:      RiO project team established and budget is on track.
                 INFORMATION -That National                                                                                                MONITORING:                          Progress from Phase I to Phase 2A achieved. BT are
                 Care Records System may not                                                                                                                                    engaged. Potential risk raised with Commissioners around
                 meet the information needs of the                                                                                                                              the impact of performance during implementation of new
                 Trust in an adequate timescale        Risk                                                                                                                     system. (S.Thompson July09)
                 which will reduce the amount of   Identification
   G-04/08                                                                   Major       Possible         9                        6                                                                                                          Q3/09       S. Thompson           S. Thompson
                 accurate/complete management       Workshops
                 information available to ensure      2008/09
                 organisation is adequately
                 controlled, has the ability to
                 evidence service delivery to the
                 Commissioners and provide readily
                 accessible clinical information
                 RISK MANAGEMENT - The Trusts                                                                                              POLICY:Risk Management               Corporate Risk Register delivered to all SSU's and review
                 risk management processes are                                                                                             Strategy.Policy & Procedure for      planned by their Board each quarter. Next phase is to
                 not embedded within the                     Risk                                                                          Reporting Incidents                  develop SSU Risk Register to compliment the corporate
                 organisation which may adversely        Identification                                                                    OVERSIGHT:Board /Board Assurance
   G-05/08                                                                   Major       Possible         9                        6                                            register.(Alan Bourne-Jones (July 09)                         Q3/09     Alan Bourne-Jones        D.McGrath
                                                          Workshops                                                                        Report MONITORING: Risk Register /
                 affect service users if risks are not
                                                            2008/09                                                                        DoH & MONITOR/Risk Manger post
                 mitigated and result in a regulatory
                 OUTCOME MEASURES - A failure                                                                                              POLICY: None OVERSIGHT: Practice The Chief Operating Officer has informed all service
                 to identify and implement consistent        Risk                                                                          Standards Cttee MONITORING:      Directors to adopt HONOS across appropriate services.
                 & robust outcome measures may           Identification                                                                    Clinical Manager System          We await the impact of PBR in mental health this year
   G-06/08       adversely affect the Trust’s ability to Workshops           Major       Possible         9                        6                                                                                                          Q3/09       S. Thompson            S.Thompson
                                                                                                                                                                                which relates to this action. The Trust will develop
                 compete and secure additional              2008/09                                                                                                             monitoring tools to report progress on this matter.
                 services                                                                                                                                                       (K.Jacobs July09)
          DATA QUALITY – Management                                                                   POLICY: OVERSIGHT:                    Qtr 1 significant data cleansing programme underway .
          information provided by key                                                                 MONITORING:                           Data quality returns now sent out to all (700+) care co-
          systems (e.g. Clinical Manager /                                                                                                  ordinators. (R.Lewis July 09)
          finance systems) may not be
G-07/08   accurate or complete which may                            Major     Possible   9        6                                                                                                        Q3/09   R.Lewis & S.Betney   S.Thompson
          adversely affect key business               2008/09
          decisions leading to;
          • Poor services/ Poor reputation
          • Regulatory breach
          COMMUNICATIONS (EXTERNAL)                                                                   POLICY: OVERSIGHT: MONITORING: All formal Trust statements and press releases written,
          – A failure to adequately control                                                                                                 agreed and distributed through the Comms Team
          information provided by the Trust                                                                                                 2. Trust colleagues encouraged to inform Comms Team of
          may lead to errors or misleading                                                                                                  all external activity and training/support provided to
          information being provided which         Identification                                                                           answer press questions/write press releases etc
G-08/08   may adversely affect the Trust’s          Workshops
                                                                    Major     Possible   9        6                                         3.Risk forever present that staff will provide comments to     Q3/09       G.Davies          S.Betney
          reputation                                  2008/09                                                                               the press without Trust agreement
                                                                                                                                            4.Strong relationships with local press (radio and print)
                                                                                                                                            developing – researchers seek clarification from Comms
                                                                                                                                            Team prior to publication.(G.Davies July)
          DELEGATED AUTHORITY                                                                         POLICY:Authorised signatories/ P2P
          (Standing Orders)– Individuals               Risk                                           system (Segregation of duties)
          acting outside of their delegated        Identification                                     OVERSIGHT: Finance
G-09/08                                                             Serious   Possible   6   8    6                                                                                                        Q3/09                        D McGrath
                                                    Workshops                                         MONITORING:Bugets/P2P system
          authority may result in a financial
          HEALTH & SAFETY -The Trust                                                                  POLICY: H&S Policy / general          All policies now updated, awaiting JNCC and Board
          fails in duty of care or to meet                                                            statement (also ST&F/DSE/Lone         ratification Managers undergoing H&S risk assessment
          Health and Safety legislation,                                                              Worker/violence Aggression etc)       training to eliminate or reduce hazards within their area of
          leading to                                                                                  OVERSIGHT:Board/Governance/Occu       control. (N.Jones July 09)
          • Increased injuries to staff,               Risk                                           pational Health & Safety Cttee/JNCC
          patients, visitors and others;           Identification                                     MONITORING:Risk assessments
G-03/08                                                             Serious   Possible   6   12   6   (Annual)                                                                                             Q3/09        N.Jones         K. Harrison
          • Increased possibility of                Workshops
          enforcement action by the                   2008/09
          enforcing authorities;
          • Increased litigation, both civil and

          STANDARDS FOR BETTER                                                                        POLICY: OVERSIGHT: Each Standard Full compliance statement given in April 2009.
          HEALTH - Failure to meet National                                                           has owner. Director of Corporate   Reassessment to commence in September.(D.McGrath
          Standards (Standards for Better                                                             affairs review MONITORING: Audit - July09)
          Health) will result in a regulatory                                                         PwC review
          breach and subsequent loss of                Risk
          reputation                               Identification
G-11/08                                                             Serious   Possible   6        4                                                                                                        Q3/09       D.McGrath        D.McGrath

          LEGISLATION - Mental Health Act                                                             Policy: Practice policies updated     Policy changes and training programme achieved for the
          (2007) & Mental Capacity Act 2005                                                           OVERSIGHT:MH Act Managers             MHA amendments, MCA and DOLs introduction
          (Depravation of Liberty Safeguards -                                                        Committee (chaired non-executive)     (V.Tweddle July09)
          DOLS) - A failure to adhere to the                                                          MONITORING: MH Administrators
          requirements of this healthcare                                                             Training: MHAct/DOLS training in
G-14/09                                                             Serious   possible   6        4   place                                                                                                Q3/09       V.Tweddle        S Thompson
          legislation may adversely affect the Workshops
          Trust’s reputation as a result of;      2008/09
          • Regulatory action
          • Legal action

          PERFORMANCE OF TRUST -                                                                      POLICY: Trusts suite of              Risk Register actions reviewed quarterly (D.McGrath July
          Poor performance identified by                                                              policies/Business plans /performance 09)
                                                       Risk                                           management OVERSIGHT: Board /
          external inspectorate, leading to
                                                   Identification                                     Board Assurance in place
G-12/08   lack of public confidence in the                          Serious   Possible   6        4                                                                                                        Q3/09       D.McGrath        D.McGrath
                                                    Workshops                                         MONITORING:Cttee structure in place
          organisation (e.g. MONITOR &
                                                      2008/09                                         /Risk Management
          Audit Commission)
          MANAGEMENT OF RECORDS – A                                                       POLICY: Health & Social care Records   Information governance Committee has approved
          failure to put in place robust                                                  Policy & Procedures OVERSIGHT:         amendments to the Information security Policy so that it is
          management of health records                                                    Practice Standards / Information       now the Information Security and Information Safe Haven
          (including their                                                                Governance Cttee MONITORING:           Policy. It will shortly be publicised in News in Brief.
          storage/retrieval/archiving) may                                                Audit (annual)
                                                                                                                                 Database is complete. Records beyond recommended
          lead to a legal/regulatory breach     Risk                                                                             retention periods have been sent to County Archives
          which may adversely affect our    Identification                                                                       Office. With the forthcoming single PAS system, we will
G-13/08                                                      Serious   Possible   6   4                                                                                                        Q3/09   P.Southam   D.McGrath
          service users and the Trust’s      Workshops                                                                           not be able to trace our case notes on PAS, which we have
          reputation.                          2008/09
                                                                                                                                 only ever been able to do in the east anyway. IT is
                                                                                                                                 developing a simple web-based case note tracking
                                                                                                                                 system. The aim is to have it in place by the end of
                                                                                                                                 October before single PAS goes live end of November.
                                                                                                                                 (P.Southam July09)

                                                          Source of       Consequence                Current Risk  Previous   Residual                                                                                                              Date of    (Corporate)
Risk Reference               Description                                                Likelihood                                                       Controls                          Summary Risk Treatment Plan (Corporate)                                              (Corporate) Risk Owner
                                                            Risk               s                        Score     Risk Score Risk rating                                                                                                            Review    Action Owners

                 CONTINUITY PLANNING - A                                                                                                   POLICY: Plans (Major                    Pandemic Flu procedure is available on the Intranet.
                 failure to adequately document and                                                                                        incident/Evacuation/Ward plans)         Supplies of essential barrier nursing equipment in stock
                 test continuity plans for the                                                                                             OVERSIGHT: Board / Emergency            and training where necessary has been completed. Trust
                 following areas may result in an                                                                                          Planning Cttee/ Multi-Agency groups     wide Pandemic Flu Business Continuity plan is now in
                 adverse impact upon services and                                                                                          (Pandemic Flu &Crisis
                                                                                                                                                                                   place and has been resilience tested and approved
                 staff. • Rikenel & IT                                                                                                     management)MONITORING:H&S
                                                    Identification                                                                                                                 formally by the board.
  OP-04/08       • Inpatient                                                Serious       Certain         10                       6                                               Individual site business continuity plans are being              Q3/09      R.Butt-Evans          S.Thompson
                 • Community                                                                                                                                                       developed and a Business Continuity Test will be
                                                                                                                                                                                   conducted during November/December. The current Trust
                                                                                                                                                                                   major Incident Plan is also available on the intranet and
                                                                                                                                                                                   will be updated following the test to include the lessons
                                                                                                                                                                                   learned from the test.(R Butt-Evans Nov09))

                 Pandemic Flu – If there is a                                                                                              POLICY:Trust – Flu Pandemic Plan +      Pandemic Flu procedure is available on the Intranet.
                 significant pandemic flu outbreak,                                                                                        supporting plans/Control Plans/In-      Supplies of essential barrier nursing equipment in stock
                 then this would adversely affect our                                                                                      surge Plans OVERSIGHT: Board            and training where necessary has been completed. Trust
                 staffing levels thereby affecting our                                                                                     NHS Gloucestershire /PCT                wide Pandemic Flu Business Continuity plan is now in
                 ability to deliver normal services                                                                                        SHA
                                                                                                                                                                                   place and has been resilience tested and approved
                                                                                                                                           MONITORING:Appointment of
                                                                                                                                                                                   formally by the Board.The SHA led Table top exercise for                   D. Furniss & R.
  OP-08/09                                                 Incident          Major       Possible         9            12                  Continuity Leads                                                                                         Q3/09                           S. Thompson
                                                                                                                                           TRAINING:Vaccination training           Chief Executives has been completed and our Pandemic                         Butt-Evans
                                                                                                                                                                                   Flu Business Continuity plans were found to be robust.
                                                                                                                                                                                   Presentation to update Board December 2010. Situation is
                                                                                                                                                                                   monitored weekly and resources remain available should
                                                                                                                                                                                   the situation changeD Furniss & R Butt-Evans Jan 10).

                 CONTINUITY PLANNING ( IT                                                                                                  POLICY: OVERSIGHT: MONITORING: I.T. Services have offered to restore a server to prove their
                 SYSTEMS) – A failure to ensure                                                                                                                                    backups are reliable. I.T. Services have been reminded this
                 robust tested plans are in place to         Risk                                                                                                                  is still a requirement – aim to complete before the end of
                 deal with the unexpected loss of IT     Identification                                                                                                            March 2009- Still waiting for I.T. to progress this.Raised for
  OP-03/08                                                                  Serious      Possible         9                        6                                                                                                                Q3/09       R Blagden             C Merker
                 systems may impact upon delivery         Workshops                                                                                                                discussion again at meeting 2July.(R.Blagden July09)
                 of services and ability to manage          2008/09
                 the organisation

                 SHARED SERVICES / THIRD                                                                                                   DM - contracts/SLA's etc                This risk has a number of elements to it and so additional
                 PARTIES – The Trust’s reliance                                                                                                                                    work required to detail potential risks relating to shared
                 upon third party                        Risk                                                                                                                      services and to then identify owners. (A.Bourne-Jones
                 organisations/companies to provide Identification                                                                                                                 July 09)                                                                    S Betney & C
  OP-01/08                                                                  Serious       Likely          8                        6                                                                                                                Q3/09                        S Betney & C Merker
                 vital services may affect the trust’s Workshops                                                                                                                                                                                                  Merker
                 ability to provide continuous high     2008/09
                 quality services should such a third
                 party cease to operate.
                 IT INFRASTRUCTURE -A failure to                                                                                           POLICY: OVERSIGHT: IT Manager           Sue O'Connell has sent out several messages in new in
                 provide adequate IT may adversely                                                                                         MONITORING: Asset management            brief and is planning a further one to remind users of the
                 affect service user care and may           Risk                                                                           project will provide monitoring (WIP)   risks of storing data locally. She is also planning a series
                 compromise data security. Clinical Identification                                                                                                                 of audits. The NAS project is almost complete and all
  OP-05/08                                                                  Serious      Possible         6                        4                                                                                                                Q3/09       R Blagden             C Merker
                 data is being stored on PCs – if        Workshops                                                                                                                 users we are aware of have been provided team and
                 they are stolen we lose the data          2008/09                                                                                                                 personal network drives to use to store information.
                 and the information could be                                                                                                                                      Various departments have had new PCs after service
                 compromised                                                                                                                                                       directors were asked for their requirements all of the
                 COMMUNICATIONS (INTERNAL)                                                                                                 POLICY: No OVERSIGHT:Asst               All formal Trust statements and press releases written,
                 – A failure to provide essential                                                                                          director Communications                 agreed and distributed through the Comms Team. 2.
                 information to staff that is accurate,                                                                                    MONITORING:                             Trust colleagues encouraged to inform Comms Team of all
                 complete and timely and in an                                                                                                                                     external activity and training/support provided to answer
                 effective manner may result in a       Identification                                                                                                             press questions/write press releases etc 3.       Risk
  OP-06/08       poor service to service users and                           Minor        certain         5                        4                                               forever present that staff will provide comments to the          Q3/09        G.Davies             S.Betney
                 staff.                                    2008/09                                                                                                                 press without Trust agreement
                                                                                                                                                                                   4.     Strong relationships with local press (radio and
                                                                                                                                                                                   print) developing – researchers seek clarification from
                                                                                                                                                                                   Comms Team prior to publication (G.Davies Mar 09)
           TELEPHONY – Should Cable &                                                             POLICY: OVERSIGHT: MONITORING: Cable & Wireless have confirmed that their notice period
           Wireless invoke the 1 months                                                                                            will be 3 months, and will work with us to ensue continuity
           notice to withdraw their service this                                                                                   of service should this eventuality arise. Given the current
           would adversely affect the standard       Risk                                                                          status of the IP Telephony contract we could delivery IP
           of care provided to our service       Identification                                                                    Telephony in this timeframe to service critical sites.
OP-02/08                                                           Minor   Possible   3   9   6                                                                                                      Q3/09   A Eggleton   C Merker
           users as there are no contingency      Workshops                                                                        (A.Eggleton July09)
           plans in place. This would impact        2008/09
           particularly on Wotton Lawn, Holly
           House and Rikenel

           ASSET REGISTER - A failure to                                                          POLICY: WIP OVERSIGHT:           Asset Management software on 90% of trust PCs – still
           maintain an up to date asset                                                           Infrastructure Committee         working with I.T. to get them to add it to all new builds. Full
           register which is subject to regular                                                   MONITORING:Asset reports bi-     audit was completed so records were accurate in
           audit and stock takes may mean                                                         monthly                          December 2008. This information will go out of date over
           loss of equipment/data without the         Risk                                                                         the next year because I.T. have no processes to
           knowledge of the executive             Identification                                                                   successfully manage change. Things are improving and
OP-07/08                                                           Rare    Possible   3       2                                                                                                      Q3/09   R.Blagden    C Merker
                                                   Workshops                                                                       we are likely to need a re-audit in early January ahead of
                                                     2008/09                                                                       RiO go Live.(R.Blagden July09)

                                                            Source of       Consequence                 Current Risk  Previous   Residual                                                                                                                Date of    (Corporate)
Risk Reference               Description                                                   Likelihood                                                        Controls                            Summary Risk Treatment Plan (Corporate)                                            (Corporate) Risk Owner
                                                              Risk               s                         Score     Risk Score Risk rating                                                                                                              Review    Action Owners

                 SERIOUS UNTOWARD                                                                                                             POLICY: Suicide                            SUI process continues to be reviewed by the Trust and NHS
                 INCIDENTS – There is a risk of a                                                                                             Strategy/CPA/Professional Regulatory       Gloucestershire. The SHA led Mental Health Network within the
                 service user being involved in a                                                                                             Bodies OVERSIGHT: Board / Clinical         SouthWest is also looking at refining processes. It is
                 serious untoward incident.                                                                                                   Risk management Cttee/ HHSLA               envisaged that the new national Serious Incident Framework
                                                                                                                                              MONITORING:Healthcare                      will roll out in 2010 improving consistency of reporting and
                                                           Identification                                                                                                                                                                                                                R Alstead &
   S-01/08                                                                    Fatality       Likely          16                      12       Commission Reviews / Clinical Audit        reviewing. Monitoring of serious untoward incidents is          Q3/09       G.Benson
                                                            Workshops                                                                                                                                                                                                                  P.Winterbottom
                                                                                                                                              /Preventing Suicide Audit/Patient          undertaken by the Governance Committee and NHS
                                                                                                                                              survey                                     Gloucestershire ( as part of the Quality Contract) (G Benson
                                                                                                                                              Annual Patient Safety Report/              Jan 2010)
                                                                                                                                              Audit of NICE Implementation
                                                                                                                                              Infection control Reports/Ligature point
                 LIGATURES -A failure to identify                                                                                             Review H&S Policy OVERSIGHT:
                                                                                                                                              POLICY:                                    Work commissioned to ensure the Trust is compliant with
                 and address potential ligature                                                                                               Board / Clinical Risk Theme Group /        all estates alerts. Proposal agreed to specify what
                 points within Trust premises has the Identification                                                                          SSU Management Boards                      constitutes level 1, 2 and 3 areas of ligature compliance
   S-03/08       potential to result in a serious                             Fatality      Possible         12           16          8       MONITORING: H&S Inspection                                                                                 Q3/09        S.Conlon            R Alstead
                                                       Workshops                                                                                                                         and what will be applicable I what setting. Funding agreed
                 untoward incident (SUI).                                                                                                     (Annual) / August 2008 Review
                                                         2008/09                                                                                                                         for additional work to implement this (V.Tweddle Nov09)

                 ESTATES (MAINTENANCE) A                                                                                                      POLICY: Policy (outstanding)/ SLA          Ligature review processes beingEstates services is being
                                                                                                                                                                                         The contract with GHNHSFT for reviewed by matrons and
                 failure to provide adequate                                                                                                  OVERSIGHT: Infrastructure Cttee            reviewed by the Director of Internal Customer Services.
                 maintenance, inspection and                                                                                                  MONITORING: Fire Assessments /              A contracts management meeting has been set up
                 testing to a level and frequency                                                                                             Estate Inspection Testing &                between GHNHSFT Estates, Procurement Shared Service
                 required to achieve safe working                                                                                             Maintenance
                                                                                                                                                                                         and 2gether Property Department to monitor individual
                 environment and statutory                                                                                                                                               contracts. New contracts, tendered through this Group
                 compliance may result in a                                                                                                                                              have 3 monthly performance monitoring meetings.
   S-02/08       significant untoward incident and/or                         Serious        Certain         10           15         10                                                  Management procedures have been agreed with                     Q3/09       A. Eggleton          C Merker
                 a regulatory/legal breach.                                                                                                                                              GHNHSFT for resolving issues . The Trust's Facilites
                                                                                                                                                                                         Manger is systematically reviewing each contract, held by
                                                                                                                                                                                         GHNHSFT on our hehalf, to ensure that all properties are
                                                                                                                                                                                         incorporated, the contract is adequate, and that the Trust
                                                                                                                                                                                         has certified copies of certificates to hold on file.(A.
                                                                                                                                                                                         Eggleton Jan 10)
                 VIOLENCE - There is a risk of                                                                                                POLICY: Violence & Aggression policy       Fire & Security Post advertised see above (N.Jones
                 violence and aggression towards                                                                                              OVERSIGHT: Board/ Governance               July09)
                 staff on inpatient units resulting in a       Risk                                                                           Cttee / Clinical Risk management
                 serious untoward incident.                Identification                                                                     Committee MONITORING: Counter
   S-05/08                                                                     Major        Possible         9                        6                                                                                                                  Q3/09         B.Ilott            C Merker
                                                            Workshops                                                                         Fraud Security Management Service
                                                              2008/09                                                                         (CFSMS) PAR’s (Physical Assault
                                                                                                                                              Reporting forms)– Annual Audit/NiCE -
                 ESTATES ( WASTE) – A failure to                                                                                              POLICY: Policy outstanding                 Contract awarded and due for implementation by October
                 dispose of the following types of                                                                                            /Segregation of Household & clinical       2009.(A.Eggleton July09)
                 waste, safely may result in a                                                                                                waste OVERSIGHT: Infrastructure
                 serious untoward incident and/or a            Risk                                                                           Cttee MONITORING:

                 legal/regulatory breach:•                 Identification
                                                                               Major        Possible         9                        6                                                                                                                  Q3/09       A.Eggleton           C Merker
                 Household (landfill & recyclable);         Workshops
                 • Clinical Waste (orange bag +               2008/09
                 sharps) and;
                 • Confidential Waste

                 EQUIPMENT SAFETY – if medical                                                                                                POLICY: Equipment management               Equipment management policy in place ( dec 08 )
                 equipment is not maintained                   Risk                                                                           policy /Decontamination,                   Registers of equipment completed and now sit with me .
                 correctly and disposed of securely        Identification                                                                     Condemnation & Disposal policy             Action plans sent to teams . Need to clarify audit
   S-07/08                                                                    Fatality      Unlikely         8                        4                                                                                                                  Q3/09       L. Forrester         R Alstead
                 in line with Trust policy there is a       Workshops                                                                         OVERSIGHT: Infrastructure Cttee            procedure for ensuring equipment maintained (L.Forrester
                 risk of injury to people.                    2008/09                                                                         MONITORING:
                                                                                                                                                                                         July 09)
                 ASBESTOS – If the extent to which                                                                                            POLICY: Management of Asbestos
                 asbestos material is located within                                                                                          PolicyOVERSIGHT: Board Delivery
                 Trust properties is not known,                                                                                               Committee MONITORING: Survey of
                 assessed and appropriate action                                                                                              all Trust properties (Type 2) Trust /
                                                           Incident (IR1      Multiple
   S-11/09       taken then there is a risk to the                                          Unlikely         6            10          4       ASBESTOS REGISTER Asbestos                                                                                 Q3/09       A.Eggleton           C Merker
                                                             ref TBC)         Fatalities
                 health & safety of staff and service                                                                                         Advice Training (1 day for Property
                 users resulting in claims for                                                                                                Dept.) / Annual Condition Assessment
                 damages and prosecution by
          POOL CARS – a failure to ensure                                                         POLICY: OVERSIGHT: MONITORING:
          pool cars are maintained in line with     Risk
          /stringent requirements of staff      Identification
S-08/08                                                          Serious   Possible   6       4                                                                                                     Q3/09   A Eggleton   C Merker
          policy may result in a serious         Workshops
          untoward incident.                       2008/09

          LONE WORKING - Staff working                                                            POLICY: Health & Safety policy / Lone   Fire &Security Manager job advertised. Lone worker
          alone without adhering to the             Risk                                          Working. Risk Assessments.              devices available through Security Management Service –
          Trust’s Lone Working policy could     Identification                                    OVERSIGHT: Local security Specialist.   awaiting responses for allocation from SSU’s. (N.Jones
S-04/08   lead to a serious untoward incident                    Serious   Possible   6   9   6   MONITORING: IR1 Reporting. Annual                                                                 Q3/09     B.Ilott    C Merker
                                                 Workshops                                                                                July09)
                                                   2008/09                                        Audit. TRAINING: Personal Safety /
                                                                                                  Conflict Resolution

          SLIPS TRIPS & FALLS - A failure                                                         POLICY: Slips Trips & Falls/ NICE   Environmental Risk Assessments to be undertaken.
          to embed a robust strategy to help                                                      Guidelines
          prevent slips, trips and falls will                                                     2004.OVERSIGHT:Quarterly /Annual
                                                    Risk                                          Report Governance/Policy Standards
          result in increased incidence of
                                                Identification                                    Committee. RIDDOR /NRLS/NHSLA.
S-09/08   injury to patients.                                    Serious   Possible   6       4                                                                                                     Q3/09   G. Benson    R Alstead
                                                 Workshops                                        MONITORING: IR1 Incident Reporting.
                                                   2008/09                                        Risk Assessments. TRAINING:
                                                                                                  mandatory H&S

          ESTATES (PHYSICAL SECURITY)                                                             POLICY: Security Policy OVERSIGHT: Awaiting appointment of LSMS. Interviews on 13th
          - Failure to secure Trust properties                                                    Governance / Infrastructure Cttee  August.(A.Eggleton July 09)
          and adhere to may result in break-                                                      MONITORING:LSMS - Annual security
          ins which could result in;                                                              audits/ IR1 Reports
          • Staff Morale/Wellbeing             Identification
S-10/08   • Loss of equipment                   Workshops
                                                                 Serious   Possible   6       4                                                                                                     Q3/09   A.Eggleton   C Merker
          • Loss of personal data                 2008/09
          • Loss of services
          • Reputation damage
                                                                                                                             STAFFING & COMPETENCY

                                                         Source of       Consequence                Current Risk  Previous   Residual                                                                                                             Date of    (Corporate)
Risk Reference               Description                                               Likelihood                                                        Controls                          Summary Risk Treatment Plan (Corporate)                                          (Corporate) Risk Owner
                                                           Risk               s                        Score     Risk Score Risk rating                                                                                                           Review    Action Owners

                 KEY PERSONNEL – The loss of              Risk                                                                            POLICY: n/a OVERSIGHT: n/a               The Assistant Director of HR – Workforce has been
                 key personnel (either temporarily or Identification                                                                      MONITORING: n/a                          working with SSU Directors to ensure that workforce
 S&C-02/08       permanently) may result in a failure Workshops            Serious       Likely          8                        6                                                                                                               Q3/09      Carol Sparks        K.Harrison
                                                                                                                                                                                   plans meet specific SSU needs (C.Sparks July09)
                 to meet legal & regulatory              2008/09
                 STRESS – Failure to effectively                                                                                          POLICY:HR linked policies - update Management action plan in place and being worked on.
                 manage work related stress will                                                                                          required OVERSIGHT:                HSE due to visit on 13 July. (N.Jones July 09)
                 result in increased absence which                                                                                        Board/Workforce cttee MONITORING:
                 may lead to;                             Risk                                                                            Risk Assessments/H&S Inspections
                 • Low morale                         Identification
 S&C-01/08                                                                 Serious      Possible         6            9           6                                                                                                               Q3/09        N.Jones           K.Harrison
                 • Adversely affect service standards Workshops
                 • Increased costs                       2008/09
                 • Enforcement action from the HSE

                 COMPETENCY – A failure to                                                                                                POLICY: Managing Performance &           1st cohort have completed and 2nd cohort has
                 achieve appropriate skill mix for                                                                                        Capability / Training Strategy Plan      commenced. Further programme planned for September
                 current & future service delivery                                                                                        OVERSIGHT: Board / Workforce Cttee       2009. The HR team have provided comprehensive training
 S&C-03/08       may adversely impact upon our                             Serious      Possible         6                        4       MONITORING:KPI’s / Complaints            in Recruitment & Retention; Absence Management;                Q3/09      Carol Sparks        K.Harrison
                 service users and affect our ability      2008/09                                                                                                                 Managing Performance for one SSU during May and June
                 to compete for services                                                                                                                                           2009. (C.Sparks July09)
                 CULTURE – A failure of staff’s                                                                                           POLICY:Trust Values – vision &           New induction programme has been running successfully.
                 ability to change to meet the ever                                                                                       Culture / Promoting Dignity at Work      Staff attending Induction are provided with an Employee
                 changing challenges faced by the                                                                                         OVERSIGHT: Workforce Cttee               Portfolio and this includes a copy of the Staff Charter. An
                 Trust may adversely affect our                                                                                           MONITORING: Staff Attitude survey        improved ‘Diversity’ slot on Corporate Induction is
                 service users and our ability to       Identification                                                                                                             planned to commence in August 2009.
 S&C-04/08       compete for services                                      Serious      Possible         6                        4                                                                                                               Q3/09      Carol Sparks        K.Harrison
                                                         Workshops                                                                                                                 Equality and Diversity training has been planned to
                                                           2008/09                                                                                                                 commence July 2009 and this will be rolled out to all staff
                                                                                                                                                                                   from July onwards, with a review in October / November
                                                                                                                                                                                   2009 of progress.(C.Sparks July09)

                 RECRUITMENT & RETENTION –                                                                                                POLICY: Recruitment & Selection     Two seminars have been held for Recruiting Managers on
                 A failure to recruit and retain the                                                                                      Policy OVERSIGHT: / Workforce Cttee how to write effective advertisements and this is
                 right calibre of staff may adversely                                                                                     MONITORING: Equalities Report       incorporated into Recruitment and Selection training.
                 affect our service users and our                                                                                                                                  Revised guidelines for managers on Recruitment is being
                 ability to compete for services            Risk                                                                                                                   finalised and will be available in July. The Job Centre have
 S&C-05/08                                                                 Serious      Possible         6                        4                                                attended Managers Briefing Sessions.                           Q3/09      Carol Sparks        K.Harrison
                                                                                                                                                                                   The NHS Jobs website has recently been upgraded and
                                                                                                                                                                                   we are currently reviewing the impact of this on Trust
                                                                                                                                                                                   processes .A summary of Trust terms and conditions and
                                                                                                                                                                                   benefits is available to all applicants(C.Sparkes July 09)

                 STATUTORY & MANDATORY                                                                                                    POLICY/TARGETS: Approved                 Currently 79% compliant against 100% target. Introduced
                 TRAINING - If staff fail to complete                                                                                     documentation for the management         Oracle (OLM) and Talent Management ( TM ) systems.
                 their mandatory training there is an     Risk                                                                            of Risk (?) KPI target 100%              Currently exploring elearning and competency based
                 increased risk to the safety of both Identification                                                                      OVERSIGHT: Board / Workforce Cttee       assessments. (K.Harrison Jan 10)                                          C Betteridge
 S&C-06/08                                                                 Serious      Possible         6                        4       MONITORING:                                                                                             Q3/09                          K.Harrison
                 service users and staff. There is a   Workshops                                                                                                                                                                                              B.Turner
                 significant dependency in being         2008/09
                 able to provide adequate evidence
                 of training having been delivered for
                 compliance purposes staff
                 STAFF ABSENCE - If                                                                                                       POLICY: Attendance management &          Staff absence continues to make positive progress. The
                 absence increases then this                                                                                              Return to Work. Trust set targets.       current rate is now standing at 4.61% and although June
                 adversely impacts on the ability to                                                                                      OVERSIGHT: Workforce Committee           and May figures were similar the trend overall for the 12
                                                            Risk                                                                          receive quarterly report. HR provide /
                 deliver care AND has a significant                                                                                                                                month rolling average period continues to be positive
                                                        Identification                                                                    present reports to SSU Boards.
 S&C-07/08       impact on budgets.                                        Serious      Possible         6                        4                                                when viewed against the Trust target. All SSU Boards           Q3/09        M.Race            K.Harrison
                                                         Workshops                                                                        MONITORING: Appraisals
                                                           2008/09                                                                                                                 are advised of the progress against absence with key
                                                                                                                                                                                   information provided on a monthly basis by HR in Service
                                                                                                                                                                                   Directorate reports (M.Race July 09)

                                                           Source of       Consequence                Current Risk  Previous   Residual                                                                                                             Date of    (Corporate)
Risk Reference               Description                                                 Likelihood                                                      Controls                           Summary Risk Treatment Plan (Corporate)                                           (Corporate) Risk Owner
                                                             Risk               s                        Score     Risk Score Risk rating                                                                                                           Review    Action Owners

                 CHANGE – A programme of                                                                                                    POLICY: OVERSIGHT: MONITORING: The Programme is operated under an MSP governance
                 significant change which is not                                                                                                                                    framework of Programme Management (OGC). Prince 2
                 planned, resourced and                                                                                                                                             methodology ensures strict monitoring of projects with
                 communicated to staff may result                                                                                                                                   exception reporting and project issue and risk logs.
                 in;                                                                                                                                                                Projects in the Programme are resourced for clear delivery
                 • Projects failing to deliver benefits                                                                                                                             dates and reviewed monthly by Programme and Project
                 • Poor service provision                                                                                                                                           Boards. All Projects and the Programme have a
                 • Poor Staff morale                          Risk
                                                                                                                                                                                    communications plan (channels appropriate to each
  ST-01/08                                                                    Major       Possible         9                        6                                               project) to develop strong links with stakeholders and          Q3/09       F.Wellbank         S.Thompson
                                                             2008/09                                                                                                                provide regular feedback. Messages are clear and
                                                                                                                                                                                    consistent identifying benefits to the organisation. The
                                                                                                                                                                                    use of the developing 'intranet' Programme area will
                                                                                                                                                                                    enhance current operating efficiency . The Programme
                                                                                                                                                                                    Risk Register is viewed at each Programme Board to
                                                                                                                                                                                    assess and mitigate risks to project delivery.(F Wallbank

                 PLANNING – A failure to plan                                                                                               POLICY: OVERSIGHT: MONITORING: The Trust has proactively approached a neighbouring
                 effectively to meet the Trust’s                                                                                                                                    Trust in difficulty with a new service which has been well
                 growth strategy may result in failure     Risk                                                                                                                     received so these opportunities will also be followed up.
                 to meet strategic targets and         Identification                                                                                                               We are now reactively following up adverts regarding
  ST-02/08                                                                    Major       Possible         9                        6                                                                                                               Q3/09       M Storrar           S.Betney
                 subsequent loss of                     Workshops
                                                                                                                                                                                    tenders to run services and proactively approaching
                 reputation/regulatory breach             2008/09
                                                                                                                                                                                    Trusts where appropriate. (S.Guinness July09)

                 ESTATES (CAPITAL                                                                                                           POLICY: Estates Strategy & Capital      CLC on programme. Likelihood = 1 (Rare) Consequence 3
                 INVESTMENT) – A failure to                                                                                                 programme/ Capital Procedure            (Major)
                 complete major capital projects        Risk                                                                                OVERSIGHT: Infrastructure Cttee /       Weavers Croft & Colliers Court, Likelihood 5 Certain,
                 (e.g. Charlton Lane Centre, Wotton Identification                                                                          Accountable Officer MONITORING:         Consequences 1 (Minor) (A.Eggleton July09)
  ST-03/08                                                                   Serious       Likely          8                        6       Finance / Budgets                                                                                       Q3/09       A.Eggleton          C Merker
                 Lawn, Weavers Croft and Colliers    Workshops
                 Court) on time and on budget may      2008/09
                 impact on the delivery of services
                 and increase costs
                 ESTATES                                                                                                                    POLICY: OVERSIGHT:
                 (DISPOSAL/ACQUISITION) -                                                                                                   MONITORING:
                 Failure to achieve an active                 Risk
                 programme of disposal and                Identification
  ST-04/08                                                                   Serious       Likely          8                        6                                                                                                               Q3/09       A.Eggleton          C Merker
                 acquisition to rationalize the estate     Workshops
                 in partnership with other                   2008/09

                 PROJECT MANAGEMENT – A                                                                                                     POLICY: Business cases /Project         Projects will be managed to Prince2 methodology. This
                 failure to adopt robust project                                                                                            Initiation Document in place /PRINCE2   strict discipline is a proven tool for risk assessment. There
                 management controls may result in                                                                                          OVERSIGHT: Board MONITORING:            is a Risk Log for each project, which is scrutinised at
                 key projects failing to deliver which Identification                                                                       Project mangers /Investment manager     every Project Board, together with an Exception Report
  ST-05/08       would adversely affect service                              Serious      Possible         6                        4       post                                                                                                    Q3/09       F.Wallbank         S.Thompson
                                                        Workshops                                                                                                                   and progress on the Project Plan. Progress is also
                 users and cause financial loss.          2008/09                                                                                                                   monitored at Project Stage Boundaries, where any
                                                                                                                                                                                    deviations to plan and deliverables are
                                                                                                                                                                                    addressed.(F.Wallbank July 09)