DOCUMENT REFERENCE NO: WE/08/PRO0004/CS

Type: PROCEDURE

Health and Safety Policy

Arrangements:
Risk Assessment Procedure and
Guidance
Relevant to:

All Pct Staff

Produced by:
Responsible Executive Director:
Date of Approval:
Date of Implementation:
Due Review Date:
Responsible Reviewing Officer:
This document replaces:

Risk, Security and Health & safety Manager

Director of Corporate Services
26.02.2010
Immediate after Approval
26.02.2012
Risk, Security and Safety Manager
Legacy PCT Risk Assessment Policies

Signed

Chief Executive

For Office Use Only

Scheme of Publication
Drive: Name:
Section
X
Scheme of
no: 5
Publication

Sub Folder:
corporate

West Essex PCT Risk Assessment Procedure & guidance

Version 2 - February 2010
Issued March 2010

File: as above

WE/08/PRO0004/CS
Page 1 of 20

POLICY VALIDITY STATEMENT

THIS POLICY IS DUE FOR REVIEW ON 26.02.2012

After this date, this document will become invalid.

Policy users should ensure that they are consulting the
currently valid version of the documentation

West Essex PCT Risk Assessment Procedure & guidance

Version 2 - February 2010
Issued March 2010

WE/08/PRO0004/CS
Page 2 of 20

RISK ASSESSMENT POLICY AND GUIDANCE

CONTENTS
Section

1.0
2.0
3.0
2.0
1.0
2.0
3.0
4.0
5.0
1
2

Section Title

Page

Cover
Policy Validity Statement
Contents
Part 1 Introduction
Introduction and Statement of Intent
Aims and Objectives
Scope and Equality Impact Assessment Statement
Relevant Legislation, Guidance and Other References
Part 2 The Risk Assessment Procedure
Introduction What is a Risk Assessment?
Definition of Terms Used
How to carry out a Risk Assessment
Risk Assessment Training
The Risk Register
Part 3 - Appendices
Risk Assessment Flowchart
The Electronic Risk Assessment Form and Guidance Sheet

West Essex PCT Risk Assessment Procedure & guidance

Version 2 - February 2010
Issued March 2010

1
2
3
4
4
4
5
6
6
6
13
12
15
16

WE/08/PRO0004/CS
Page 3 of 20

Part 1 Introduction
1.0

Introduction and Statement of Intent

NHS West Essex takes extremely seriously the health, safety and welfare of all staff.
It recognises that in carrying out its undertaking risks will be identified that need to
managed and controls introduced to mitigate the risks in order to prevent harm, loss
or damage to individual staff, members of the public including patients and the
organisation.
This guidance takes into account the requirements of the law relating to the
management of risk and risk assessment, as well as up to date guidance from the
Department of Health.
The Trust also recognises it has an obligation under the Health and Safety at Work
Act 1974 and the Management of Health and Safety at Work Regulations 1999, for
the health, safety and welfare at work of its staff and others. These responsibilities
apply equally to ensure that there is proper management of identified risks, and that
staff understand the requirements placed upon the Trust.
This guidance document forms an integral part of the Arrangements Section of the
Trusts Corporate Health and Safety Policy. The roles and responsibilities of staff
that are detailed within that Policy are applicable to this guidance and procedure
document.
Where additional duties/responsibilities are identified relating specifically to Risk
Assessment, these will be detailed within this document, but must be read in
conjunction with those contained within the Health and Safety Policy.
2.0

Aims and Objectives

This document has been developed:

a)

To provide guidance on the identification and management of risk;

b)

To ensure that the management of risk is compliant with current legislative

requirements, and that risk assessments are carried out in such a manner that
they are fit for purpose.

3.0

Scope and Equality Impact Assessment Statement

This document has been assessed for equality impact. It is applicable to every
member of staff within the PCT irrespective of their race, ethnic origin, nationality,
gender, culture, religion or belief, sexual orientation, age or disability.
This document is to be available to all Trust employees at all times. Managers must
ensure that staff have read and are aware of the content of this guidance document.
All new members of staff joining the Trust should be asked to read this guidance as
part of their basic induction.
West Essex PCT Risk Assessment Procedure & guidance
Version 2 - February 2010
Issued March 2010

WE/08/PRO0004/CS
Page 4 of 20

4.0

Relevant Legislation, Guidance and Other References

Health and Safety at Work etc Act 1974

Management of Health and safety at Work Regulations 1999
Regulatory Reform (Fire Safety) Order 2005
(It should be noted that the majority of recent health and safety related legislation
contains a requirement for risk assessment).
NHS West Essex Integrated Governance Strategy
NHS West Essex Corporate Health and Safety Policy

The Management of Health and Safety at Work Regulations 1999 Approved Code
of Practice and Guidance (L21)
HSE 5 Steps to Risk Assessment Guidance (INDG 163)
HSE A Guide to Risk Assessment Requirements (INDG 218)
Boyle, T (Dr) Health and Safety Risk Management, Institute of Occupational Safety
and Health Publishing, 2000
Roberts, G (Dr) Risk Management in Healthcare, Witherby/Institute of Risk
Management, 2002 (2nd Edition)
Bateman, M Practical Risk Assessment Handbook, Butterworth Tolleys, 2001 (2nd
Edition)
NPSA - A Risk Matrix for Risk Managers, January 2008

West Essex PCT Risk Assessment Procedure & guidance

Version 2 - February 2010
Issued March 2010

WE/08/PRO0004/CS
Page 5 of 20

Part 2 The Risk Assessment Procedure

1.0

Introduction What is a Risk Assessment?

The Health and Safety Executive (HSE) describe risk assessment as nothing more
than a careful examination of the hazards associated with work activities and
premises that could cause harm to people, so that you can weigh up whether you
have taken enough precautions or should do more to prevent harm. The important
things that you need to decide are whether a hazard is significant, and whether
satisfactory precautions are in place so to minimise the risk.
Risk assessment is part of good management. It can be used to determine the risk
to people from the physical workplace and the activities that are undertaken within
that workplace. It can also be used when developing new services, or designing new
premises in order to design out the risks to people by designing in the necessary
control measures.
Anyone can undertake a risk assessment, although there are a number of specific
assessments, such as manual handling, new and expectant mothers and workstation
assessments where some specialist training is required. Details of these
assessments will be provided in other procedure documents. The risk assessment
procedure contained within this document is usable by any member of staff.
2.0

Definition of terms used:

Hazard: anything with the potential to cause harm

Risk: the likelihood that a hazard will cause a specified harm to someone or
something.
(Source: The HSE)
3.0

How to carry out a Risk Assessment

An abridged printable version of this procedure and the risk assessment form
are contained at Appendix 2 and are available on the intranet
3.1

Use the NHS West Essex Trust General Risk Assessment Form.

3.2

Identify the hazards in the workplace, activity, environment or service.

Ignore the trivial and focus on significant hazards which could result in serious
harm or affect several people. Some common hazards and/or hazardous
activities include:

Violence and aggression, including verbal abuse directed at staff

Lone working
Blocked fire exits, lack of procedures
Slip, trip and fall hazards eg wet floor, floor covering in poor condition
Damage to fabric of building eg walls, windows, fixtures such as sockets

West Essex PCT Risk Assessment Procedure & guidance

Version 2 - February 2010
Issued March 2010

WE/08/PRO0004/CS
Page 6 of 20

Electricity eg damage to sockets, no appliance testing, no circuit testing

Manual handling including supporting and manoeuvring patients
Lack of personal protective equipment (PPE)
Poor lighting both internally and externally
Use and Disposal of sharps
Administering medicines
Contact with bodily fluids and clinical waste
Commissioning of Services
Development of Services
Compliance with legislation or standards
Budget management

3.3

Who may be harmed? Identify the persons who may be harmed. You should
consider not only staff, but also students/trainees, patients, visitors,
contractors, cleaners, maintenance workers. Consideration should also be
given to pregnant women and those with a disability or impairment. Refer to
people in groups ie staff, visitors, patients not by name or position. Having
identified who might be harmed, consider how many within each group of
people might be harmed.

3.4

Existing control measures provide details of existing control measures. In

other words, look at what precautions are already in place to control risks.
Remember control measures include for example:
Physical Controls/Barriers such as locks, cabinets, fences
Training if staff have attended appropriate and relevant training courses,
e.g. manual handling, fire awareness, personal safety, corporate induction
and risk management etc this should be specified in the existing control
measures column on the risk assessment form.
Working instructions, procedures and policies that have been put into place
and communicated to staff will give clear instructions with regard to the
working arrangements. Control measures that have been put into place
will be detailed within the individual policies, procedures or working
instructions.
Personal Protective Equipment (PPE). PPE is described as all equipment
which is intended to be worn or held by a person at work and which
protects against one or more risks to health and safety , e.g. gloves, eye
protection, footwear etc.

3.5

Evaluate the Risk. Having identified the hazards/hazardous activities, who

might be harmed, and considered the existing control measures that are in
place, an evaluation of the risk needs to be made. The evaluation process
enables the risk assessor to decide whether existing control measures are
adequate or if additional measures need to be taken.

3.6

Risk Evaluation Methodology & Tables. The tables below provide the
methodology to carry out evaluate your risk assessment. Having identified the
hazards, the risk rating is evaluated by asking and answering two questions:

West Essex PCT Risk Assessment Procedure & guidance

Version 2 - February 2010
Issued March 2010

WE/08/PRO0004/CS
Page 7 of 20

(i) What is the likelihood of harm occurring? Has this hazard/activity caused
harm before, if so how often? Talk to colleagues and others in your place of
work
(ii) Will loss, injury or harm occur, and if so how severe will it be?
Note. The Risk Rating = Likelihood of Causing Harm x Severity of Outcome
Likelihood of Occurrence

Likelihood
What is the likelihood that harm, loss or damage from the identified hazard will occur
Likelihood
score
Descriptor
Frequency
How often
might it/does
it happen

1
Rare
This will
probably never
happen/recur.

Possible
Do not expect it
to happen/recur
but it is
possible it may
do so

Probable
Might happen
or recur
occasionally

Certain

Will probably
happen/recur
but it is not a
persisting issue

Frequent
Will
undoubtedly
happen/recur,
possibly
frequently

Severity of Outcome
Severity
If an injury, loss or damage occurs, how severe will it be?

Domains
Impact on the
safety of
patients, staff
or public
(physical/
psychological
harm)

1
None
Minimal injury
requiring
no/minimal
intervention or
treatment.
No time off
work

2
Minor
Minor injury or
illness, requiring
minor
intervention

5
Moderate
Moderate injury
requiring
professional
intervention

10
Significant
Major injury
leading to longterm
incapacity/disabili
ty

Requiring time
off work for >3
days

Requiring time
off work for 4-15
days

Increase in
length of
hospital stay by
1-3 days

Increase in
length of
hospital stay by
4-15 days

Increase in length
of hospital stay
by >15 days

RIDDOR/
agency
reportable
incident

Mismanagement
of patient care
with long-term
effects

Requiring time off

work for >15
days

15
High
Incident leading
to death
Multiple
permanent
injuries or
irreversible
health effects
An event which
impacts on a
large number of
patients

An event which
impacts on a
small number of
patients

West Essex PCT Risk Assessment Procedure & guidance

Version 2 - February 2010
Issued March 2010

WE/08/PRO0004/CS
Page 8 of 20

Domains
Quality/
complaints/
audit

1
None
Peripheral
element of
treatment or
service
suboptimal
Informal
complaint/
inquiry

2
Minor
Overall
treatment or
service
suboptimal
Single failure to
meet internal
standards not
significant
Minor
implications for
patient safety if
unresolved

Human
resources/
organisational
development/s
taffing/
competence

Short-term low
staffing level
that
temporarily
reduces
service quality
(< 1 day)

Reduced
performance
rating if
unresolved
Low staffing
level that
reduces the
service quality

5
Moderate
Treatment or
service has
significantly
reduced
effectiveness

Repeated
failure to meet
internal
standards not
significant
Prolonged
suboptimal
treatment or
service
Late delivery of
key objective/
service due to
lack of staff
Staffing levels
below minimum
levels >1 day <
5
Low staff
morale
Poor staff
attendance for
mandatory/key
training

Statutory duty/
inspections

No or minimal
impact or noncompliance of
guidance/
statutory duty

Breech of
statutory
legislation
Reduced
performance
rating if
unresolved

10
Significant
Non-compliance
with national
standards with
significant risk to
patients if
unresolved
Multiple
complaints/
independent
review
Low performance
rating
Critical report

15
High
Totally
unacceptable
level or quality
of treatment/
service
Gross failure of
patient safety if
findings not
acted on
Inquest/ombuds
man inquiry
Significant
failure to meet
national
standards

Uncertain
delivery of key
objective/service
due to lack of
staff

Non-delivery of
key
objective/servic
e due to lack of
staff

Staffing levels
below minimum
levels > 5

Ongoing unsafe
staffing levels or
competence

Loss of key staff

Loss of several
key staff

Very low staff

morale
No staff attending
mandatory/ key
training

Single breech in
statutory duty

Enforcement
action

Challenging
external
recommendatio
ns/
improvement
notice

Multiple breeches
in statutory duty
Improvement
notices
Low performance
rating
Critical report

No staff
attending
mandatory
training /key
training on an
ongoing basis
Multiple
breeches in
statutory duty
Prosecution
Complete
systems change
required
Zero
performance
rating
Severely critical
report

West Essex PCT Risk Assessment Procedure & guidance

Version 2 - February 2010
Issued March 2010

WE/08/PRO0004/CS
Page 9 of 20

Domains
Adverse
publicity/
reputation

1
None
Rumours
Potential for
public concern

2
Minor
Local media
coverage
short-term
reduction in
public
confidence

5
Moderate
Local media
coverage
long-term
reduction in
public
confidence

10
Significant
National media
coverage with <3
days service well
below reasonable
public
expectation

Elements of
public
expectation not
being met

Business
objectives/
projects

Finance
including
claims

Insignificant
cost increase/
schedule
slippage

Small loss
Risk of claim
remote

<5 per cent over

project budget
Schedule
slippage

510 per cent

over project
budget
Schedule
slippage

Loss of 0.1
0.25 per cent of
budget

Loss of 0.25
0.5 per cent of
budget

Claim less than

10,000

Claim(s)
between
10,000 and
100,000

Non-compliance
with national 10
25 per cent over
project budget
Schedule
slippage
Key objectives
not met
Uncertain
delivery of key
objective/Loss of
0.51.0 per cent
of budget
Claim(s) between
100,000 and 1
million
Purchasers
failing to pay on
time

15
High
National media
coverage with
>3 days service
well below
reasonable
public
expectation. MP
concerned
(questions in
the House)
Total loss of
public
confidence
Incident leading
>25 per cent
over project
budget
Schedule
slippage
Key objectives
not met
Non-delivery of
key objective/
Loss of >1 per
cent of budget
Failure to meet
specification/
slippage
Loss of contract
/ payment by
results
Claim(s) >1
million
Permanent loss
of service or
facility

Service/
business
interruption
Environmental
impact

Loss/interrupti
on of >1 hour

Loss/interruptio
n of >8 hours

Loss/interruptio
n of >1 day

Loss/interruption
of >1 week

Minimal or no
impact on the
environment

Minor impact on
environment

Moderate
impact on
environment

Major impact on
environment

Breaches
of
Confidentiality

Minor breach of
confidentiality,
only a single
individual
affected

Potentially serious
breach up to 20
people affected

Serious breach of
confidentiality e.g.
up to 100 people
affected

Serious breach with

either particularly
sensitive
e.g.
sexual
health
details, or up to
1000
people
affected

Serious
breach
with potential for
ID theft or over
1000
people
affected

No
significant
reflection on any
individual
or
body,
media
interest
very
unlikely

Damage to an
individual
or
teams reputation.
Possible
media
interest

Damage to a
services
reputation.
Low
key local media
coverage

Damage
to
an
organisations
reputation.
Local
media coverage

Damage to NHS
reputation.
National
media
coverage

West Essex PCT Risk Assessment Procedure & guidance

Version 2 - February 2010
Issued March 2010

Catastrophic
impact on
environment

WE/08/PRO0004/CS
Page 10 of 20

1
None

2
Minor

5
Moderate

10
Significant

15
High

Attainment
levels
show
negligible
improvement
year on year

Attainment levels
remain same as
previous year

Unable to show
continued
improvement
in
attainment levels
year on year

Unable to achieve
required attainment
level in 1 or more
key (Statement of
Compliance)
requirements

Unable to achieve
required
attainment level in
1 or more key
(Statement
of
Compliance)
requirements

Signifcant/High will
depend on criteria
unable to achieve

Signifcant/High
will depend on
criteria unable to
achieve

Domains
Information
Governance
Standards

Risk Rating Table

Risk Rating Table Likelihood x Severity

Severity
Likelihood

Frequent
5

None

Minor

Moderate

Significant

High

1
5

2
10

5
25

10
50

15
75

Certain

20

40

60

Probable

15

30

45

Possible

10

20

30

Rare

10

15

Risk Rating for Risk Assessment Matrix

Risk Rating 1-4
Very Low Risk, Control measures effective or harm/severity small.
Monitor risk for change and reassess if necessary
Risk Rating 5-10

Low Risk, probability of harm to organisation is low if control measures

not implemented. Action required within 6 months

Risk Rating 15-30

Moderate Risk, probability of harm to organisation is moderate if

control measures not implemented. Action required within 3 months.

Risk Rating 40-60

High Risk, probability of harm to organisation is significant if control

measures not implemented. Urgent action required. Action required
within 1 month or consider stopping procedure.

Risk Rating 75

Unacceptable Risk Take immediate Action. The stopping of a

procedure/process/service may need to be considered

West Essex PCT Risk Assessment Procedure & guidance

Version 2 - February 2010
Issued March 2010

WE/08/PRO0004/CS
Page 11 of 20

Reporting/Review Arrangements
Risk Rating 1-4

Very low risks: Risk subject to aggregate review, to be monitored by

Directorate.

Risk Rating 5-10

Low risks: are acceptable to the Trust, any actions required to reduce
risk will be responsibility of Directorate to fund.

Risk Rating 15-30

Moderate risks: copies of risk assessment forms, along with timetable

and action plans will be agreed and monitored by the Executive Team

Risk Rating 40-60

Significant risks: will be reported to the Finance, Corporate and

Commissioning Group along with proposed treatment plans, for action.
Actions to be implemented as per the remedial plan and within 3
months where possible.

Risk Rating 75

High risks: will be reported to the Audit Committee, with proposed risk
remedial plans to mitigate the risk. Actions to be implemented as per
the remedial plan and within 1 month where possible.

3.7

Where the risk is not adequately controlled or needs to be improved.

Having determined the risk rating, you should now consider what can be done
to reduce the level of risk. If the risk rating score falls in the red area, you will
need to look at what you can do by way of introducing additional measures to
reduce that to a score to the lowest possible level.
Ultimately, you should be looking toward a risk rating score within the green
zone. However, it is recognised that this is not always possible even after the
introduction of additional measures, or if the risk is outside of PCT control.
The actions that are to be taken to reduce the risk rating should be noted on
page 2 of the assessment form, along with who is responsible for taking the
action, target dates for completion of the actions and whether there are any
constraints on the completion of the actions..

3.8

Monitoring, Reviewing and Revision of Risk Assessments

Carrying out a risk assessment is not a one off exercise, they need to be
reviewed and revised at least annually or earlier if there have been significant
changes to working practices, equipment, the environment, or the legislation
has changed or there have been changes to standards or guidance.

3.9

Risk Assessment Communication

Risk assessments are live documents that need to be communicated to all
relevant persons, by either the assessor or Line Manager/Team Leader. Line
managers will ensure staff have a full understanding of the risk assessment(s)
and the measures and systems put into place to ensure the risks are
adequately controlled.

West Essex PCT Risk Assessment Procedure & guidance

Version 2 - February 2010
Issued March 2010

WE/08/PRO0004/CS
Page 12 of 20

An integrated governance structure has been put into place to ensure all
significant risk management issues, including health and safety issues are
communicated to the Integrated Governance Committee, the Board
Assurance Framework, the Audit Committee and the Trust Board.
Copies of completed risk assessment should be forwarded to the Risk,
Security and Safety Manager for consideration and inclusion into the
Corporate Risk Register.
3.10

Risk Assessing a Patient

In general the Patient Record would act as the principal risk assessment for a
patient. It contains all the relevant information that needs to be gathered
about the patient such as nature of illness, current & previous treatment plans,
patient handling assessments, personal care risks, any underlying conditions
that could lead to aggressive or unexpected behaviour, allergies etc.
This form can be used in support of documentation contained within the
Patient Record, but should not be used as a replacement for any specific
records and documentation.

4.0

Risk Assessment Training

This Risk Assessment Procedure and Guidance will be communicated to all
staff and will form part of the What Governs You Induction Training. It is also
available on the intranet.
Practical risk assessment training workshops will be arranged for nominated
Risk Assessors. Refresher training sessions will also be programmed.

5.0

The Risk Register

The Risk Register is separated in to two parts Commissioning Arm and
Provider Arm. The Commissioning risk Register is managed by the Risk,
Security and Safety Manager, whilst the Provider Risk Register is managed by
the Provider Services Head of Integrated Governance. It is populated with all
identified risks that could have a significant impact upon the organisations
business objectives, compliance with standards or statutory duties.
The Risk Registers are discussed by the Executive Team on a bi-monthly
basis. Red Risks are reported to the Audit Committee and the Board on a
regular basis. The Risk Registers support the organisations Business Plan
and Assurance Framework

West Essex PCT Risk Assessment Procedure & guidance

Version 2 - February 2010
Issued March 2010

WE/08/PRO0004/CS
Page 13 of 20

Part 3 Appendices

Appendix
Number

Title of Document

Risk Assessment Flowchart

The Electronic Risk Assessment Form And Guidance Sheet

West Essex PCT Risk Assessment Procedure & guidance

Version 2 - February 2010
Issued March 2010

WE/08/PRO0004/CS
Page 14 of 20

RISK ASSESSMENT FLOWCHART

Appendix 1

The flowchart summaries the risk assessment process, for further guidance refer to
the HSEs Five Steps to Risk Assessment Guidance leaflet www.hse.gov.uk
IDENTIFY THE HAZARD/ACTIVITY that is
anything with the potential to cause significant harm

DECIDE WHO MIGHT BE HARMED there is no

need to list individuals by name, just consider the
groups of peopleand the numbers

WHAT EXISTING CONTROL MEASURES DO YOU

HAVE IN PLACE?
This means looking at the preventative and
protective measure already taken

EVALUATE THE RISK. IS MORE NEEDED TO

CONTROL THE RISK?
For the hazards listed in your risk assessment do
the precautions already taken:
meet the standards set by a legal
requirement?
Comply with a recognised industry standard?
Represent good practice?
Minimise the risk to the lowest level possible?
Have you provided:
Adequate information, instruction and training
to those who need to know?
Are adequate systems orprocedures in
place?
Where the risk is not adequately controlled, indicate
what more you need to do on Page 2 of the risk
assessment form

REVIEW AND REVISE the risk assessment at least

annually or when there have been changes in
working practices or the legislation
West Essex PCT Risk Assessment Procedure & guidance
Version 2 - February 2010
Issued March 2010

WE/08/PRO0004/CS
Page 15 of 20

Appendix 2

THE ELECTRONIC RISK ASSESSMENT FORM AND GUIDANCE SHEET

Risk assessment forms and this guidance can be downloaded from the Intranet or
are available from the Integrated Governance Team.
The forms require completion twice, once to identify the hazards/risks and where
action is required and not implemented at the time of the risk assessment, a second
copy needs to be completed with details of action(s) and implementation.
Page 1 of Risk Assessment Form
Step 1.

Either print off the assessment form or save it electronically under a

different file name that is relevant to the risk assessment. Complete the
first two rows of the risk assessment document as follows: the location part is the area for example The Laurels. The exact
location part is the area where the assessment is being carried out
e.g. the photo-copying room
the Manager Responsible is the Person who has responsibility for
that area / service
the Reason for Assessment is what has promoted the risk
assessment to be undertaken.

Step 2.

Decide whether or not you are carrying out your risk assessment on an
activity, process or hazard, and explain what it is e.g. trailing wires
(hazard) or Use of Electrical Equipment (activity). Enter this in the
Activity/Risk to be assessed on the form.

Step 3.

List the hazards that have been identified with that activity, process or
hazard, i.e. tripping over the trailing wires. Use a separate box for each
one.

Step 4.

Detail what existing control measures are in place NOW, to reduce the
risk e.g. cable covers for trailing wires, safety guards on electrical
equipment, personal protection (gloves, goggles). Consider if these are
adequate and working.

Step 5.

Detail who might be harmed by the risk e.g. Staff, Patients and Visitors
and how many at any one time. You also need to consider anyone who
may come into the department, area where risk assessment has been
under taken. This needs to include anyone that may come into the
area after hours like Domestic Staff.

West Essex PCT Risk Assessment Procedure & guidance

Version 2 - February 2010
Issued March 2010

WE/08/PRO0004/CS
Page 16 of 20

Step 6.

Consider what is the likelihood of the hazard causing harm, you must
be realistic and use past history like reported accidents / near misses.
Ask the staff that work in the area, ask other colleagues if that have
experienced this risk. Use the Risk Scoring Matrix for reference and
detail the identified number in the likelihood column.

Step 7.

Consider the severity of any harm should it occur, again look at the Risk
Scoring Matrix. Put the identified number in the severity column.

Step 8.

Multiply both these numbers together to get your risk rating and enter
this in the risk rating column.

Page 2 of Risk Assessment Form

Step 9.

List what actions you feel need to be taken to reduce the risk level.

Step 10.

Detail the person(s) responsible for taking the action required.

Step 11.

Agree a target date for when action should have been taken by. The
time scale should represent the risk rating, higher the score the quicker
action needs to be taken, for example
Significant
High
Moderate
Low
Very Low

Immediately
Within 3 month
Within 6 months
Within 9 months
Within 12 months

If you are unable to take the action required within an appropriate

timescale this needs to be highlighted on the form.
Step 12.

Add any additional comments you feel are relevant.

Step 13.

List any constraints for achieving your actions, such as budgetary

constraints, target date.

Step 14.

Once the assessment form has been completed a copy should be

forwarded to the Governance Team at the Laurels, St. Margarets
Hospitals, where it will be entered onto the Trust Risk Register. The
original should be kept in the area/services to which the assessment
relates.

Step 15.

Once the action required has been taken / implemented, an updated

copy of the risk assessment form should be completed with details of
the actions and timescales and a copy sent to the Governance Team to
update the Risk Register.

If you are unsure of anything, please contact the Governance Team on 01279
827163 and they will be happy to assist.
West Essex PCT Risk Assessment Procedure & guidance
Version 2 - February 2010
Issued March 2010

WE/08/PRO0004/CS
Page 17 of 20

RISK SCORING MATRIX

Why do Risk Assessments?
How to complete assessment form?
Assessment of risk is required across the Trust to ensure
that the risks arising out of or in connection with work are
either reduced, eliminated (preferred option) or controlled
so far as is reasonably practicable. This includes
hazards such as:

Financial

Clinical

Ergonomic, (including Manual Handling)

Physical = Trips/Slips/Falls/Violence etc

Environmental = Waste/Pollution

Psychosocial (Stress)
It is the responsibility of all Directors to ensure that risk
assessments are carried out thoroughly and
appropriately ensuring that the form is signed when
completed. Copies of all risk assessment forms MUST
be sent to the Risk Manager.
How is risk scored?
Risk assessment allows for the measurement,
quantification and prioritisation of risk with a view to
removal or reduction to an acceptable level. This is
achieved by the simple process of multiplication of the
potential likelihood of a risk occurring with the severity
of its occurrence.
To achieve a risk rating, you need to look at the
definitions under likelihood and chose the most
appropriate, and then the definitions under severity and
again chose the most appropriate. Once you have
these numbers, look on the risk matrix and match the
two together, to obtain risk rating. You then need to tick
the appropriate colour box on the risk assessment form.

Very low risks:

Low risks:
Moderate risks:
Significant risks:
High risks:

Severity

None
1

Minor
2

Moderate
5

Significant
10

High
15

Likelihood
Frequent
Certain
Probable
Possible
Rare

5
4
3
2
1

Likelihood
1
2
3
4
5
Severity
1

5
4
3
2
1

Descriptor
Rare
Possible
Probable
Certain
Frequent
Descriptor
None

Minor

Moderate

10

15

Significant

High

10
8
6
4
2

25
20
15
10
5

50
40
30
20
10

75
60
45
30
15

Example of Descriptor
The event may occur only in exceptional circumstance
May occur at some time
Will occasionally re-occur
Will occur in most circumstances
Is certain to occur in most circumstance
Example of Descriptor
No injuries. Financial loss < 100 and no service
disruption.
Temporary injury resulting in absence from work 1 3
days or increased length of patient stay. Financial loss
101 - 1,000. No adverse publicity.
Semi-permanent injury resulting in absence from work
3 15 days or increased length of stay 8 15 days.
Financial loss 1,000 - 10.000. Local adverse
publicity likely.
Major injury resulting in absence from work > 15 days
or increased length of stay > 15 days, temporary
closure to services, financial loss 10.000 - 50,000,
potential national publicity
Death or multiple injuries. Major disruption to services,
financial loss > 50,001. Protracted national adverse
publicity. Extended closure of services.

IDENTIFY
HAZARDS

Look at the risks

that could have an
impact on the
organisation, staff
or patient.

EXISITNG
CONTROL
MEASURES

Consider any
control measures in
place at time of
assessment, that
reduce the risk.

WHO MIGHT
BE HARMED

Consider all those that

could be at risk,
including staff working
out of hours.

ASSESS THE
RISK

ACTION
REQUIRED

MONITOR AND
REVIEW

You need to multiply

the likelihood against
severity to obtain your
level of risk, this is
called a risk rating.
This is the action
required to reduce the
level of risk, which
must be implemented
Periodically review
e.g. via new
legislation, practices
and equipment.

Risk subject to aggregate review, to be monitored by Directorate, action to be taken to reduce risk if appropriate.
Are acceptable to the Trust, any actions required to reduce risk will be responsibility of Directorate to fund, action to be taken to reduce risk if appropriate.
Copies of risk assessment forms, along with timetable and action plans will be agreed and monitored by the Risk Action Group.
Will be reported to the Executive Committee along with proposed treatment plans, for action. Actions to be implemented within 3 months and audited by the board
Will be reported to the Board, with proposed treatment plans for action. Actions to be implemented within 1 month and audited by Board

West Essex PCT Risk Assessment Procedure & guidance

Version 2 - February 2010
Issued March 2010

WE/08/PRO0004/CS
Page 18 of 20

Risk Assessment Form

Provider/Commissioning/Both (delete those not applicable)

Service Speciality

Locality

Assessment Date:

Location:

Exact Location:

Manager Responsible:

Completed by:

Contact Details:

Reason for Assessment:

Activity / Risk(s) to be assessed:

Identified Hazard(s)

Existing control Measures

West Essex PCT Risk Assessment Procedure & guidance

Version 2 - February 2010
Issued March 2010

Who might
be Harmed

WE/08/PRO0004/CS
Page 19 of 20

Likelihood
(L)

Severity
(S)

Risk Rating
(L x S)

Action Plan to Control/Treat/Mitigate Risks

(if no action can be taken please note this below)
Summary of Actions required to Minimise or Remove Risk
(Consider what action needs to be taken to reduce the level of risk e.g. making
changes to the working environment, identifying training needs, introducing changes
to working practices, maintaining existing or purchasing new equipment, wearing
PPE, communicating

Person responsible
for taking this
action
(Give name and title)

Target
Date(s)

Constraints for achieving actions

and target date(s),

Assessment Review Dates

1st Review

2nd review

3rd review

Name of Assessor

Signature

Name of Manager Responsible for Actions:

4th review
Signature

Please keep the original copy of the risk assessment at the premises/services to which it relates. A copy of the completed form should be
forwarded to the Governance Department at The Laurels, SMH within 7 days of completion for entry onto the PCT Risk Register.
For Governance use only:

Received Date:
ID:

Input Date:
Title:

Follow UP:

West Essex PCT Risk Assessment Procedure & guidance

Version 2 - February 2010
Issued March 2010

WE/08/PRO0004/CS
Page 20 of 20

Initials:

Ref: