Risk Assessment Policy and Protocol.doc

8/18/2019 Risk Assessment Policy and Protocol.doc

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Risk Assessment Policy

Version 4

Name of responsible (ratifying) committee Risk Assurance Committee

Date ratified 4th February !"#

Document $anager (%ob title) Deputy Director of Nursing&'ead of atient afety

Date issued "st $arch !"#

Re*ie+ date February !", (unless re-uirements change)

.lectronic location $anagement olicies

Related rocedural Documents

Risk $anagement trategy

/uidance for the de*elopment of a ustainable0ransformation rogramme (inc 1uality 2mpact Assessment)

3ey ords (to aid +ith searching)

Risk Assessment olicy5 rotocol Risk Register5'a6ard in*entory5 Risk management5 Risk factors5atient safety5 taff health and safety5 re*enti*emeasures5 Accident pre*ention5 Contingency planning

2n the case of hard copies of this policy the content can only be assured to be accurate on the dateof issue marked on the document7

For assurance that the most up to date policy is being used8 staff should refer to the *ersion held on

the intranet

Version Date ratified Brief Summary of Changes

Author

# !9&!#&"" 'ead of Risk $anagementand :egal er*ices

4 !4&!&"# :inks to R$ trategye;plicit:inks bet+een RiskRegister and


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CONTENTS

!"C# RE$ERENCE %!"DE&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&'

(& "NTROD!CT"ON&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&)

*& P!RPOSE&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )

'& SCOPE&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&)

)& DE$"N"T"ONS&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& )

+& D!T"ES AND RESPONS"B","T"ES&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&+

-& PROCESS&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& .

.& TRA"N"N% RE!"RE/ENTS&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&(0

1& RE$ERENCES AND ASSOC"ATED DOC!/ENTAT"ON&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&(0

2& E!A,"T3 "/PACT STATE/ENT&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&((

(0& /ON"TOR"N% CO/P,"ANCE&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&(*

A.ND2C.= Appendi; A= />2DANC. F?R A.2N/ 0'. R23 Appendi; 2DANC. ?N C?$:.02?N ?F 0'. R23 R./20.R Appendi; .= :ist of 0rust pecialist Ad*isers

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!"C# RE$ERENCE %!"DEFor -uick reference the guide belo+ is a summary of actions re-uired7 0his does not negate the needfor those in*ol*ed in the process to be a+are of and follo+ the detail of this policy7

0he purpose of a risk assessment is to pro*ide a systematic and methodical tool for identifying risksassociated +ith legal8 moral and financial duties8 remo*ing them +here possible8 or other+iseadopting all the control measures and precautions that are reasonable and practical in thecircumstances7

(& "dentify the riskRisks may be identified through a *ariety of mechanisms=

• From +alking around your +orkplace and looking afresh at +hat could reasonably be

e;pected to cause harm7 .7g7 change in practice & ne+ e-uipment

•


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(& "NTROD!CT"ON

ortsmouth 'ospitals N' 0rust accepts that some of its acti*ities may8 unless properlycontrolled8 create risks to patients8 staff8 *isitors8 contractors and others8 and +ill endea*our totake all reasonably practicable measures to reduce these risks to an acceptable le*el7

0o achie*e this8 the 0rust needs to understand its risks8 ho+ they are being controlled andprioritised8 +hilst recognising the guidance pro*ided by national bodies8 e;isting legislation andthe 0rusts pecialist Ad*isers

0he broadest sense of harm and potential harm to the 0rust8 and its ability to deli*er the -ualityser*ices to +hich it aspires8 must be the focal point for this e;ercise7

*& P!RPOSE

0he purpose of this policy is to pro*ide clear instructions on the identification of ha6ards andthe process and management of those ha6ards8 +ith regard to risk assessment7 0his +illenable the 0rust to acti*ely monitor8 manage8 prioritise and de*elop a consistent approach to allrisk assessments7 2t +ill ensure=

A consistent approach to managing all risks clinical8 financial8 en*ironmental and

organisational and the actions necessary to reduce each risk

A robust mechanism for the integrated prioritisation of all risks

Risk Registers (0rust+ide or local) that are contributed to by all management teams

and 0rust specialist ad*isers

taff are a+are of their roles and responsibilities +ithin the assessment process

0he 0rust (ortsmouth) and Carillion8 +hilst ackno+ledging that for staff other than those directly employed by the 0rust the appropriate line management or chain of command +ill be taken into account7 hilst the policy outlines ho+ the 0rust +ill manage itsrisks8 implementation does not replace the personal responsibilities of staff +ith regard toissues of professional accountability for go*ernance7

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognisesthat it may not be possible to adhere to all aspects of this document. In such circumstances,staff should take advice from their manager and all possible action must be taken tomaintain ongoing patient and staff safety’

)& DE$"N"T"ONS

Controls 0he a*ailable systems and processes +hich help minimise the risk

Conse8uence 0he impact or outcome component of a risk8 on a scale of " B ,

,ikelihood 0he probability of a risk occurring or recurring8 on a scale of " B ,

9a:ard Anything +ith the potential to cause harm

Risk ossibility of e;posure to the ha6ard and therefore the chance of in%ury8 ill

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health8 harm8 damage or loss7 2t may include substances8 e-uipment8 a+ork practice or proposed business plan

RiskAssessors

Competent persons +ho possess the kno+ledge8 skills and e;perienceto undertake a risk assessment

RiskAssessment

A process by +hich information is collected about an e*ent8 process8organisation or ser*ice area8 in order to identify e;isting risks&ha6ards8the conse-uence and the likelihood of harm and +hat control measures

are in place8 or are re-uired to be put in place7

Risk Rating .ach risk is rated8 using a , ; , matri;8 (conse-uence ; likelihood)8 +hichdetermines +hether the risk is ranked as green8 yello+8 amber or red7(Appendi; A)

Reacti6eRisks

Risks that are identified follo+ing an e*ent8 such as an incident8complaint or audit

Proacti6eRisks

Risks that are identified before they cause an e*ent8 or that are beinglooked for during the audit process

Residual RiskRating

0he remaining risk that e;ists follo+ing implementation of the proposedmeasures or controls to reduce the risk

Res4onsi;le,ead

0he person +ith the responsibility for ensuring that actions to control therisk are implemented

+& D!T"ES AND RESPONS"B","T"ES

+&( All Staff

2t is the responsibility of all 0rust employees to=


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5.4 Department Managers/Leads

All departments must ha*e a risk register7 0he Departmental $anager is responsible for

ensuring risks are identified8 assessed8 recorded8 reported8 monitored8 and re*ie+ed i7e7managed +ithin their area using the approach described in this policy and procedure8 incon%unction +ith the Clinical er*ice Centre (CC) $anagement 0eam and rele*ant risk

specialists e7g7 'ealth and afety Ad*isor7 0his is an ongoing process and should includeboth proacti*e and reacti*e situations7

+&+ Clinical Ser6ice Centre


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+&2 Risk Assurance Committee


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• .;ternal Assessment&Audit including= Care 1uality Commission8 Clinical

Negligence cheme for 0rusts (maternity)8 National 'ealth er*ice :itigation Authority Risk $anagement tandards8 2nternal Audit8 Audit Commission

• National Confidential .n-uiries8 National er*ice Frame+orks8

Recommendations from other e;ternal high le*el en-uiries and reports

-&*&* Assessing the risk Although the 0rust has a standard risk assessment template8 there are no fi;edrules about ho+ the assessment should be carried out= it +ill depend on the natureof the undertaking and the type and e;tent of the ha6ards and risks7 Risks andha6ards are identified on a daily basis throughout the 0rust by all staff membersand the risks&ha6ards +ill *ary significantly in conse-uence and likelihood andhence the measures for addressing them +ill also *ary7

'o+e*er8 the process should be practical8 participati*e8 systematic8 and co*er risks +hich are reasonably foreseeable7 For small undertakings +ith fe+ or simpleha6ards a suitable and sufficient risk assessment can be a straightfor+ard processbased on personal %udgment8 e;perience and kno+ledge7 2n larger or morecomple; cases8 specialist kno+ledge may be re-uired7 hate*er the type of risk

assessment8 it should be suitable and sufficiently detailed to determine +hether ade-uate control has been achie*ed7

Consider +ho or +hat is at risk7 Do not forget

oung +orkers8 trainees8 ne+ and e;pectant mothers etc8 +ho may be at

particular risk

Cleaners8 *isitors8 contractors8 maintenance +orkers8 etc +ho may not be

in the +orkplace all the time

$embers of the public8 or people +ith +hom you share your +orkplace8 if

there is a chance they could be harmed by your acti*ities

0rust reputation or financial position

?nce a risk has been identified a risk assessment should be completed using thestandard template (Appendi;


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• 2f not8 +hat controls need to be in place so that the conse-uence8 should

the risk be reali6ed and the likelihood (chance) of the risk occurring8 can beeliminated or reduced as far as is reasonably practicable

• hen are the additional controls likely to become effecti*e (target date)

• hat assurance +ill 2 be able to get as to +hether the controls are

+orking

• hat the predicted (residual) risk rating is likely to be once all the controls

are in place• ho +ill monitor implementation of the action plan

-&*&) /onitoring 5 re6ie7ing the risk All risks should be placed on a risk register and progress monitored at theappropriate le*el on a monthly basis7 0here are three types of risk register8 allbased on the same risk register template (Appendi; C)7 /uidance on completion isat Appendi; D

• pecialty risk registers

• CC risk registers

• 0rust risk register

-&' Risk Registers

-&'&( S4ecialty risk registers0hese are held by each specialty&department and monitored at least -uarterly bythe responsible team7 Any risk that the specialty considers cannot be managed atthat le*el8 has the potential to affect the CC in +hich the specialty is located8 or scores ", or abo*e (red) should be escalated to the rele*ant CC go*ernancemeeting for consideration of inclusion on the CC risk register

-&'&* CSC risk registers

0hese are held by each CC and monitored at least -uarterly by the CCgo*ernance meetings7 Any risk that the CC considers cannot be managed at thatle*el8 has the potential to affect the 0rust as a +hole8 and&or scores ", or abo*e(red) should be escalated to the Risk Assurance Committee for consideration andescalation to the 0rust risk register

-&'&' Trust Risk Register 0his is monitored monthly by the Risk Assurance Committee and -uarterly by the0rust


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assurance across all # documents7 0he Risk Coordinator coordinates this process+ith the risk o+ners8 on behalf of the Risk Assurance Committee and 0rust


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• 'eporting of Injuries, 1iseases and 1angerous +ccurrences 'egulations "#23

('I11+')2nternal0his policy is applicable to clinical and nonclinical issues= it is of great importance that it shouldbe read in con%unction +ith other appropriate 0rust strategies and policies7 0he follo+ingdocuments are a good starting point=

• Risk $anagement trategy

• C?'' olicy

• :one orker olicy

• Display creen .-uipment olicy

• $anual 'andling olicy

• Fire olicy

• /uidance for the De*elopment of a ustainable 0ransformation rogramme

(inc 1uality 2mpact Assessment)

All trategies and olicies may be accessed *ia the 0rust 2ntranet7 2f you do not ha*e access tothe 2ntranet8 please ask your line manager

2& E!A,"T3 "/PACT STATE/ENT

ortsmouth 'ospitals N' 0rust is committed to ensuring that8 as far as is reasonablypracticable8 the +ay +e pro*ide ser*ices to the public and the +ay +e treat our staff reflectstheir indi*idual needs and does not discriminate against indi*iduals or groups on any grounds7

0his policy has been assessed accordingly

Risk Assessment olicy Version 4 !"&!#&!"# age "" of !(Re*ie+ date= February !", unless re-uirements change)

http://www.porthosp.nhs.uk/Health-and-Safety-Policies/COSHH%20Regulations%202002%20Policy%20as%20amended%202004.dochttp://www.porthosp.nhs.uk/Health-and-Safety-Policies/Lone%20worker%20Policy.dochttp://www.porthosp.nhs.uk/Health-and-Safety-Policies/Safe%20use%20of%20display%20screen%20equipment%20DSE%20Policy.dochttp://www.porthosp.nhs.uk/Health-and-Safety-Policies/Manual%20handling%20operations%20of%20inanimate%20loads.dochttp://www.porthosp.nhs.uk/Management-Policies/Fire%20Policy.dochttp://www.porthosp.nhs.uk/Management-Policies/Fire%20Policy.dochttp://www.porthosp.nhs.uk/Management-Policies/Fire%20Policy.dochttp://www.porthosp.nhs.uk/Management-Policies/Fire%20Policy.dochttp://www.porthosp.nhs.uk/Management-Policies/Fire%20Policy.dochttp://www.porthosp.nhs.uk/Management-Policies/Fire%20Policy.dochttp://www.porthosp.nhs.uk/Management-Policies/Fire%20Policy.dochttp://www.porthosp.nhs.uk/Health-and-Safety-Policies/COSHH%20Regulations%202002%20Policy%20as%20amended%202004.dochttp://www.porthosp.nhs.uk/Health-and-Safety-Policies/Lone%20worker%20Policy.dochttp://www.porthosp.nhs.uk/Health-and-Safety-Policies/Safe%20use%20of%20display%20screen%20equipment%20DSE%20Policy.dochttp://www.porthosp.nhs.uk/Health-and-Safety-Policies/Manual%20handling%20operations%20of%20inanimate%20loads.dochttp://www.porthosp.nhs.uk/Management-Policies/Fire%20Policy.dochttp://www.porthosp.nhs.uk/Management-Policies/Fire%20Policy.dochttp://www.porthosp.nhs.uk/Management-Policies/Fire%20Policy.doc


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(0& /ON"TOR"N% CO/P,"ANCE

Element to ;e monitored ,ead Tool $re8uency of Re4ortof Com4liance

Re4orting arrangements ,ead


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A44endi> A

%!"DANCE $OR ASSESS"N% T9E R"S#S0he risk matri; belo+ is simple to use and designed to assist you in assessing risk in a consistentand systematic +ay= %ust follo+ each step of the process

Ste4 (? 2f the risk occurred +hat are the likely conse-uences (C) to person(s) or the 0rust >se thetable belo+ to grade the conse-uence

CONSEQUENCE

SCORE (1 – 5)

1 2 3 4 5

Insignificant/None(Green)

inor(!e""o#)

o$erate(%&'er)

aor(Re$)

Etre&e(Re$)

In*r+ (,-+sica" /,s+c-o"ogica")

Adverse event leading tominor injury not requiring

first aid and managedsatisfactorily on the ward

Minor injury or illness, first aidtreatment needed

Staff sickness


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%$.erse0*'"icit+ /Re,*tation

9overage in the media,little effect on #u$lic

confidence " staff moral

=u$lic #erce#tion of theorganisation would remain

intact

+ocal media 2 short term%Minor effect on #u$licattitude " staff morale

=u$lic #erce#tion of theorganisations may alter

slightly $ut with no significantdamage or disru#tion

+ocal media 2 long term%

9onsidera$le adverse #u$licreaction " staff morale may $e

affected

:ational media < 3 days%1sage of services affected

=u$lic confidence in trustundermined could result in

major #ro$lems

:ational media B 3days%concern &questions in the 6

Major adverse #u$lic reac

No Of 0ersons%ffecte$ :"A 50- 305? 5D0? B?

Ste4 *? :ook at +hat is being assessed and ask the -uestion= hat is the likelihood (:) of harm topersons or the 0rust8 gi*en the current controls&precautions in place >se the table belo+ to gradethe likelihood7

,"#E,"9OOD DESCR"PTOR DESCR"PT"ON

" Rare Not e;pected to happen again e;cept only in e;ceptionalcircumstances e7g7 once a decade8 or a probability of K"L

>nlikely 0he e*ent may re occur infre-uently8 but it is a possibility e7g7 once a

year or a probability of ",L# ossible 0he e*ent may re occur e7g7 once a month8 or a probability of E!L

4 :ikely 0he e*ent +ill probably re occur e7g7 +eekly or a probability of ",!L

, 'ighly likely 0he e*ent is likely to re occur on many occasions8 is a constantthreat e7g7 at least once a day or probability of B,!L7 $ore likely tooccur than not7

Ste4 '? 0o obtain the risk rating8 multiply the conse-uence ; the likelihood

CONSEQUENCE

IEIOO6 1Insignificant

2inor

3o$erate

4aor

5Etre&e

1 – Rare:ot e#ected to occur

1O7

2O7

3O7

4O6ER%8E

5O6ER%8E

2 – Un"i9e"+!ccurs infrequently

2O7

4O6ER%8E

:O6ER%8E

;SIGNIIC%N8

1<IG

3 – 0ossi'"e!nce or twice a year

3O7

:O6ER%8E

=IG

12IG

15E>8REE

4 – i9e"+6a*ard will occur $ut isnot #ersistent%4here are no issues of

custom and #ractice%

4O6ER%8E

;IG

12IG

1:E>8REE

2<E>8REE

5 –Certain9onstant threat iscustom and #ractice

5O6ER%8E

1<IG

15E>8REE

2<E>8REE

25E>8REE

Risk Ranking0hese are applied for purposes of ranking the risk for use and for reporting to the National atientafety Agency (NA)

:o+ (" G #) 'igh Risk (H G ")

$oderate Risk (4 G E) .;treme Risk (", G ,)

Ste4 )? Risk ,e6el and Action Re8uired&

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Score Risk Pre6entati6e /easures to ;e Taken or Planned

(@' :o+ Risk G manage by routine procedure7 2mplement any action that +ill eliminate&control the riskRemains Departmental Risk Register

)@- $oderate Risk G $anagement action must be specified7 0he departmental manager must de*ise8 agreeand implement an action plan to reduce or eliminate the risk7 Department Risk Register

1@(* 'igh Risk G enior $anagement action7 0he CC $anagement 0eam must be a+are of any risks scoring" or abo*e and the Departmental $anager must de*ise and implement an action plan to reduce8 controlor eliminate the risk7 Risk must be inputted onto CC Risk Register (score of " or abo*e) and 0rust RisRegister +here appropriate (see Risk $anagement olicy)7

(+@*+ .;treme Risk G 2mmediate action re-uired7 0he CC $anagement 0eam must be made a+are and ar responsible for ensuring an in*estigation and action plan is commenced immediately to reduce8 control8 oeliminate the risk7 0he risk must be inputted onto the CC Risk Register and 0rust Risk Register aappropriate according to the Risk $anagement olicy7

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A44endi> B

R"S# ASSESS/ENT AND ACT"ON P,AN

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T3PE + matri>


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9os4ital Site A95S/9 Date

Clinical Ser6ices Centre Assessor

Dir5De4t5S4ecialty5ard

"D 5CCRef

T 3 P E 5 S O

! R C E @

D A T E O P

E N E D

R"S# 5 9AARDDESCR"PT"ON

"/PACT ACT"VE CONTRO,SA,READ3 "N P,ACE

" N " T " A , R " S #

R A T " N %

D%!"DANCE ON CO/P,ET"ON O$ T9E R"S# RE%"STER

SECT"ON CO//ENTS

f No • A number +hich allo+s the risk to be uni-uely identified= this +ill inserted8 once the risk

is placed on the register

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pe • 0his is outlined on the top of the risk assessment form

te • 0he date the risk +as first placed onto the Register

sk Description • A statement that pro*ides a brief8 unambiguous and +orkable description8 +hich enables

the risk to be clearly understood8 analysed and controlled

nse-uence • 0his is the conse-uence should the risk be realised

elihood • 0his is the chance of the risk being realised

ti*e Controls • Details of any actual controls already in place i7e7 factors that are e;erting material

influence o*er the risks likelihood and impact= the risk rating7

• An effecti*e control is one that is properly designed and deli*ers the intended ob%ecti*e &

mitigates the risk

tial Risk Rating • 0he rating determined by likelihood ; conse-uence using the , ; , matri;

o Conse-uence= the impact should the risk occur this score should take into

account the e;isting controls

o :ikelihood= the likelihood of the risk happening this score should take into account

the e;isting controls

rrent Risk Rating • 0his +ill initially be the same as the initial risk rating

• As time progresses8 the current risk rating should decrease (if your controls are

appropriate and effecti*e) and mo*e closer to the predicted residual risk rating

rther actions • Further action(s) re-uired to be taken in order to eliminate8 mitigate or control the risk

ogress >pdate • A brief update on progress made since the last re*ie+7 N


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sponsible :ead • 0his is you and you should

o >nderstand the risk and monitor it through its lifetime

o .nsure the appropriate controls are enacted

o Report on the risk +hene*er re-uired to do so

sponsiblemmittee

• 0he Committee +hich has responsibility for monitoring progress of the management of

the risk

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A44endi> E

,ist of Trust S4ecialist Ad6isers

S4ecialist Ad6iser Contact Details

Control of 2nfection 99!! EE"

Falls 99!! EE9,

'ealth and afety 99!! #E4,

$anual 'andling 99!! #E4

Radiation rotection 99!! #II

Risk $anagement 99!! #49I

0issue Viability 99!! EIH,