984BoardAssuranceFrameworkandRiskQuarterlyReportEnclosureTii45

South Warwickshire NHS Foundation Trust Risk Register Appendix B

Collated by Joanne Beales, Risk Manager - 13 January 2012 1 of 6

Current TotalsDecember

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RISK REGISTER 2011 - 2012 Current Open Risks with Initial Score of 15 or above as at 1 January 2012 (not included on BAF)

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1 614 4 5 20 20 16 16 3 4 12 2/24/2012

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1 620 Clinical treatment reduction 4 5 20 20 10 10 2 5 10 2/24/2012

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Person / Group Monitoring

Controls / Actions Required

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Reduced staffing levels - Leamington District Nurses.

Lack of staff capacity due to increased patient referrals resulting in the District Nurses being unable to complete documentation, report incidents and CPAS entries' on a daily basis.

General Manager - Integrated Adult Services

1. One nurse per day is assigned to triage all referrals, manage urgent telephone calls and organise the workload.2. Professional Lead supporting the Lead Nurse and team twice per day.3. Virtual Ward team to offer support with daily workload.4. Leg ulcer clinic to close for August 2011.5. Ambulant Patient Clinic commenced 04.06.2011.6. Bank nurse booked for 15 hours per week.

Integrated & Community Care Risk Health & Safety Group

RMB 13/06/2011 - Recruitment in progress. Reduce to 4:4.25/11/2011 - Risk reviewed by ICC Health & Safety Committee risk remains the same.06/12/2011 - (RMB) - Risk rating reduced to 3:4

1. 5 staff vacancies to be filled by October 2011.2. Consider capacity / demand for team.3. To continue with reduction of student allocation until team fully staffed.

Professional Lead - Leamington District Nurses

Children's speech and language therapy services to be reduced due to Warwickshire County Council giving 6 months notice on its contract for £266,000 which will result in reduced services and redundancies.

Head of Children, Young People and Family Services

1. In order to reduce the potential costs of redundancy CSD have not been appointing to Paediatric SLT posts.2. Communicated to staff and schools to make them aware if the risk of cuts.3. Built in 6 month notice period into CSDs SLA with WCC.4. WCC has confirmed funding of £170,000 for Children’s SLT for 2012/135. Established a traded ser vice arm to SLT. Income for this financial year is approx £30,0006. Predicted income for next year extrapolated from this year’s figures is £45,000, so far.


RMB 13/06/2011 - Reduce to 2:5.25/11/2011 - Risk reviewed by ICC Health & Safety Committee risk remains the same.06/12/2011 - (RMB) - Risk remains the same.

1. NHS Warwickshire (NHSW) has agreed to underwrite the cost of 3wte posts until the end of the financial year, to provide time to establish income through traded service.2. NHS Warwickshire to cover costs of redundancies, if income generation fails.3. Redundancy plan drawn up - NHSW agreement, current vacancies and staff volunteering to reduce sessions will preclude the need for redundancy.

Speech & Language Therapy Manager




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1 629 Manager A&E 4 5 20 12 3 4 12 15/02/2012

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1 618 4 4 16 16 16 4 4 16 10/01/2012

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11 621 Increased Referrals 4 4 16 16 16 16 3 2 6 Ongoing 29/06/2012

Trust wide capacity issues impact on A&E Dept ability to provide high standards of care and ensure patient safety

Trust wide capacity issues impacting on the A&E Department ability to provide high standards of care and ensuring patient safety. The department regularly does not have sufficient cubicle space to assess, care and treat patients. Patients frequently in A&E corridor with ambulance crews as we are unable to off load. Patients present directly or via ambulance service to A&E and patient activity between 150 - 190 patients per day with approximately 55 admissions. This could result in:Delay in assessing potentially sick and injured patientsDelay in initiating treatmentInability to provide regular monitoring for patientsReduction in ability to provide adequate privacy and dignityIncrease risk of errorIncrease risk of complaintsIncrease risk of violence & aggression towards staffStaff unable to take breaks

Trust capacity escalation policyDepartmental escalation planCohorting of ambulance patient procedure with support from the HALO.Twice daily bed meetings, these are increase depending on level of capacity issues.Bank and Agency staff used to support both long term and short term sickness.A&E staff working extra shifts

Cross Divisional Risk Health & Safety Group

This risk replaces Risk # 582: Ad hoc extra bed capacity opened at short notice due to increased bed demand.06/12/2011 (RMB) - Risk Score amended 3:4 due to increased staffing levels and improved environment.

Staff security - Bedworth Health Centre.

Lack of security on door leading to department resulted in members of the public gaining access to lone workers.

ADO - Support Services

Sign post at the base of the stairs to stop access as much as possible.

Support Services Risk Health & Safety Group

06/12/2011 - (RMB) - Health & Safety Committee to suggest alternative measures.

Fix a digi lock to the door which is linked to the fire alarm system.Awaiting capital funding.

General Manager - Estates

Increase in patient referrals to SLT Stroke Outreach will exceed capacity of service resulting in patients not being assessed or treated within service standard.

General Manager - Integrated Adult Services

1. Priority for patients with dysphagia.2. Telephone advice offered.3. Referrals decreased.


RMB 13/06/2011 - Awaiting report from Commissioners.25/11/2011 - Risk reviewed by ICC Health & Safety Committee risk reduced to 3x2=6.06/12/2011 - (RMB) - Risk rating agreed.

1. Triaging system by therapist to allow effective prioritisation of referrals and patients' advised of waits for treatment.2. Patients offered initial assessment for dysphasia and simple communication difficulties transferred to a generalist community SLT team.

Neuro Rehab Manager




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1 622 Late recording on CPAS 4 4 16 16 9 9 1 2 2 30/11/2012

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1 612 Insuffucuent Dietetic Cover. 4 4 16 16 16 16 Workload monitoring. 3 3 9 14/02/2012

Adverse impact on organisational finances due to lack of / late recording on CPAS resulting in financial loss.

ADO - Integrated & Community Care

1. Activity reviewed monthly.2. CPAS training for new starters and CPAS Refresher training.3. Data Quality Group convened.4. Reports within Evolve are being distributed appropriately with team leaders, to monitor activity.5. Data cleansin commences June 2011, in Adult Services.6. Connectivity Audit available to help understand issues with connectivity.Checking compliance through audits.7. Reference to good quality data mentioned at mandatory training sessions.CPAS Data Quality Group receives bi-monthly progress / update reports.


RMB 13/06/2011 - Reduce to 3:3. Agreed by Risk Assessors.25/11/2011 - Risk reviewed by ICC Health & Safety Committee risk regraded 1x2=2. To be reviewed in 12 months.

Insufficient dietetic cover at RLSRH - Campion (0.5 day per week) & Arden (3.5 hrs per fortnight) Wards and Ellen Badger Hospital (2 hrs per month) because of increased referrals for nutrition risk screening (50 - 233% increase)1. Patients identified at high risk of malnutrition should be seen by a Dietitian as per Trust standard for screening. The increase in referrals has resulted in delays in patients being seen.2. Increased hospital stays.3. Delayed discharges.



13/06/2011 - (RMB) - risk needs to be clarified -review next meeting06/07/2011 - Risk reviewed by SMT - risk remains12/09/2011 - (RMB) - Risk to be reviewed by risk owner to include nursing staff and matrons. Review at next meeting.06/12/2011 - (RMB) - Risk rating reduced to 3:3 due to staff being recruited.

Increase dietetic staffing levels for RLSRH & EBH.Loss of SLA with partnership trust from end of March 2012 released additional half day cover for RLSRH. Staffing levels will continue until end of March 2012.Submitted requirements for dietetics for Acquired Head Injury Unit - additional 0.4 wte given - waiting for funding to come through.

Dietetic Services Manager




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1 583 4 4 16 16 16 16 3 2 6 12/06/2012

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10 551 4 4 16 16 16 12 4 3 12 15/02/2012

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0 557 Director of HR 5 3 15 15 10 10 5 2 10 07/02/2012

Failure of electrical supply to equipment, including overheating

Domestic extension leads in a commercial environment. Failure of electrical supply to equipment, including overheating which may lead to fire and possible lass of lives. Within the trust an external audit verified 259 of these non-commercial extension leads being used. This is also an alert that had been issued by the DH in 2007 which to this day hasn't been closed


Yearly Portable appliance testing (PAT) in place to identify areas


06/12/2011 - (RMB) - Risk rating reduced to 3:2 due to work being completed at Warwick & Stratford Hospitals. Assessment in the Community has taken place, plan to remove unnecessary extension leads. Costings for adequate extension leads to be presented to Capital & Estates for funding.

No assessment area for neutropenic patients admitted directly to ward.

Direct admissions to Farries ward of out-of-hours of patients presenting with neutropenic sepsis or chemotherapy related complications. Risk occurring as no assessment space available for these patients.

Associate Director of Operations (Medicine)

Bed managers to leave bed empty on Farries Ward if hospital capacity allows. 2 patients in side rooms must be fit to be relocated at anytime to accommodate this risk.


17/08/2011 (CDRG) - Further controls added and management plans in place. Risk assessment to be updated but scoring has been reduced.12/09/2011 - (RMB) - To be resubmitted to Risk Management Board via Cross Divisional Risk Group.06/12/2011 - (RMB) - Risk remains the same. Pathway has been written and will be discussed at a meeting on Agency doctors do not always

have an appropriate and documented handover/induction

Agency doctors do not always have an appropriate and documented handover/induction when undertaking locum shifts because there is non-compliance with current process which may result in medical errors and unsafe clinical practice.Failure of locums to pick up documentation despite explicit instructions to do so.Established locum induction procedure not being effectively completed or undertaken.Booking of locums' out of hours procedure not fully completed.

Locum Booking Procedure and Agency Locum Booking Procedure and documentation.

Corporate Risk Group

08/03/2011 (CRG) - Audit report has now been completed and will be presented to Management Board on 18 March 2011. Risk remains the same. Take forward to next CRG meeting.13/06/2011 (RMB) - repeat audit to be presented to September Management Board28/06/2011 (CRG) - Director of HR advised that the quarterly audit will be issued to Management Board every 6 months. Risk remains the same.06/12/2011 - (RMB) - Risk remains the same, although improvement in the number of inductions being carried out. 3 monthly audits continue. Escalation procedure implemented.




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RISK REGISTER 2011 - 2012 Accepted Risks

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6 8 Staffing- Maternity Unit Head of Midwifery 5 3 15 8 8 8 4 2 8 3/2/2012

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8 339 Director of Nursing 5 3 15 10 10 10 5 2 10 2/7/2012

Failure of complete nurse call system

Failure of complete nurse call system & unavailability of a stand-by wireless system due to the stand by wireless system being used on another ward this could result in - no contact from patient to nurse station. Verbal calls made by patients which may not be heard - patient care failure - potentially fatal. System failure - no contact from patient to nurse station. Verbal calls made by patients - cannot be heard - patient care failure - potentially fatal



12/09/2011 - (RMB) - Risk accepted, to be reviewed at quarter 4 Risk Management Board meeting.

General Manager - Estates

Staffing- Maternity Unit. Birthrate Plus, workload/staffing tool, has recommended that the service requires a further 20 WTE midwives. The present financial position of the Trust is unable to meet the recommendations. A business case was submitted to the PCT for consideration in the LDP but was not agreed. The Midwifery team will need to consider reconfiguring and/or re-profiling the service to meet the CNSY Level 3 standard

Awaiting approval at Trust Board for extra staffing - Midwifery Manager has had discussions with Director of Finance. Extra workload is anticipated , so extra funding is being considered.

Maternity Risk Management Group

13/12/2010 (RMB) - Board has agreed to review. Risk remains the same.

The use of Domestic type extension leads may lead to fire which could result in fire damage to the hospital and injury to the staff/patients.

The use of Domestic type extension leads may lead to fire which could result in fire damage to the hospital and injury to the staff/patients. This risk follows the issue of Estates and Facilities Division Alert DH (2007) 06.

Director of Development

2 year ongoing programme.Audit and PAT Testing.


11/01/2011 (CRG) - Risk accepted. Review in 12 months time.

Storage, usage and preparation of Concentrated Formaldehyde solution (40%)/ Formal saline(10%)

Preparations of solution - risk of skin and eye contact, risk of inhalation of fumes, spillage, incorrect formula for preparation, storage of solution when prepared, COSHH regulations not adhered to, insufficient spillage kits available, lack of procedure.

Associate Director of Operations (Surgery)

Current procedure for spillages exists.1. Training occurs for path lab personnel on induction to department 2. Unsure/sporadic training elsewhere in Trust 3. Procedures followed correctly once spillage occurs 4. Availability of special masks in areas.


15/12/2010 Cross Divisional Risk Group - Risk is being managed by department. Risk score remains the same.

NPSA Safer Practice notice 14- ability to assess competence -2

Serious hazard of transfusion due to lack of competency assessment of staff involved in transfusion process

Self assessment 'on line' electronic transfusion training package 'ORAS' available within the Trust.Annual Mandatory transfusion training commenced July 2008


11/01/2011 (CRG) - Risk accepted. Review in 12 months time.




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009 366 5 3 15 10 10 10 5 2 10 2/7/2012

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09 492 Head of Midwifery 5 3 15 8 8 8 4 2 8 02/03/2012

Non-compliance with Electrical Safety (low voltage) statutory standard

The Trust may be non-compliant to statutory standard relating to electrical safety (low voltage), because areas have not been electrically tested, which could result in an injury to patients or staff.Ensure compliance with statutory standards - requirements to new HTM and regulations. Testing not up to date, training on safety procedures for staff not up to date.

Director of Development

Work carried out to previous HTM.New audit in progress to new HTM.


Agreed at 08/03/2011CRG that review of this risk should be brought forward to 28 June 2011 CRG.28/06/2011 (CRG) - Risk remains the same. Review at next meeting.23/08/2011 (CRG) - Risk accepted. To be reviewed at next meeting.15/11/2011 (CRG) - Electrical compliance tests were now taking place in the community. Access to wards was required as power has to be completely turned off in each ward to complete tests. Consideration for work to be completed over a weekend and patients decanted to the 23 hour ward during tests.

SCBU corridors used for storage

Lack of storage has caused the hallways and corridors of SCBU to be cluttered with spare incubators and other mobile equipment/trolleys posing a risk to patients, visitors and staff for possible injuries while blocking the route in case of a fire. As SCBU has a high profile in the community there is a risk to the Trust's reputation if a serious incident was to occur. There is a risk of damaging expensive equipment.

There are no control measures except the awareness of staff to the potential risks when moving patients in incubators, they are aware that they must move the stored equipment in the corridor first before moving a patient.

Maternity Risk Management Group

05/07/10 - Reviewed by Maternity Risk Management Group - some work has been done but further improvement needed. Risk score unchanged.14/03/2011 (RMB) - Risk accepted.

Documents

984BoardAssuranceFrameworkandRiskQuarterlyReportEnclosureTii45