984 Board Assurance Frameworkand Risk Quarterly Report Enclosure Tii 45

Appendix B
South Warwickshire NHS Foundation Trust Risk Register
Likelihood
Total
20
16
16
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 3
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
12
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
2/24/2012
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, 4
Young People and
Family Services
20
20
10
10
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 Childrens SLT for
2012/13
5. Established a traded
ser vice arm to SLT.
Income for this
financial year is approx
30,000
6. Predicted income
for next year
extrapolated from this
years figures is
45,000, so far.
Integrated &
Community Care
Risk Health &
Safety Group
RMB 13/06/2011 - Reduce 2

to 2:5.
Committee risk remains the
same.
06/12/2011 - (RMB) - Risk
remains the same.
10
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
2/24/2012
Control Measures / Person / Group

Actions Presently in
Monitoring
Place
Outcome from meeting
Consequence
20
Sep-11
Jun-11
General Manager - 4
Integrated Adult
Services
Mar-11
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.
Risk Owner
Total
Current Risk
Rating
December
Controls /
Actions
Required
Description
Likelihood
Risk / Hazard
Consequence
Date added
Source:
Incident/ RA
etc
Initial Risk Current Totals

Rating
ID
Who
When
Review
Date
Risk Assessment
25 March 2011
614 Reduced staffing levels Leamington District Nurses.
Risk Assessment
31 March 2011
RISK REGISTER 2011 - 2012 Current Open Risks with Initial Score of 15 or above as at 1 January 2012 (not included on BAF)
620 Clinical treatment reduction
Collated by Joanne Beales, Risk Manager - 13 January 2012
1 of 6
Appendix B
16
Increase in patient referrals to SLT Stroke General Manager - 4

Outreach will exceed capacity of service Integrated Adult
resulting in patients not being assessed Services
or treated within service standard.
16
ADO - Support
Services
16
Total
Lack of security on door leading to

department resulted in members of the
public gaining access to lone workers.
Likelihood
20
Current Risk
Rating
December
Consequence
Sep-11
Risk Owner
Jun-11
Trust wide capacity issues impacting on Manager A&E

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 patients
Delay in initiating treatment
Inability to provide regular monitoring for
patients
Reduction in ability to provide adequate
privacy and dignity
Increase risk of error
Increase risk of complaints
Increase risk of violence & aggression
towards staff
Staff unable to take breaks
Description
Mar-11
Total
621 Increased Referrals
Likelihood
618 Staff security - Bedworth

Health Centre.
Consequence
25 May 2011
Date added
27 July 2011
629 Trust wide capacity issues

impact on A&E Dept ability to
provide high standards of care
and ensure patient safety
31 March 2011
Risk / Hazard
Incident
ID
Risk Assessment
Source:
Incident/ RA
etc

Rating
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.
12
15/02/2012
Sign post at the base

of the stairs to stop
access as much as
possible.
Support Services 06/12/2011 - (RMB) - Health

Risk Health &
& Safety Committee to
Safety Group
suggest alternative
measures.
16 Fix a digi lock to General

the door which is Manager linked to the fire Estates
alarm system.
Awaiting capital
funding.
10/01/2012
1. Priority for patients

with dysphagia.
2. Telephone advice
offered.
3. Referrals
decreased.
Integrated &
Community Care
Risk Health &
Safety Group

Monitoring
Place
12
Trust capacity
Cross Divisional
escalation policy
Risk Health &
Departmental
Safety Group
escalation plan
Cohorting 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
16
16
16
16
2 of 6
RMB 13/06/2011 - Awaiting

report from Commissioners.
Committee risk reduced to
3x2=6.
06/12/2011 - (RMB) - Risk
rating agreed.
Controls /
Actions
Required
Who
6 1. Triaging
Neuro Rehab
system by
Manager
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.
When
Ongoing
Review
Date
29/06/2012
Appendix B
16
16
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 bimonthly progress /
update reports.
Integrated &
Community Care
Risk Health &
Safety Group
Insufficient dietetic cover at RLSRH ADO - Support

Campion (0.5 day per week) & Arden (3.5 Services
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.
16
16
16
16
Workload monitoring.
Support Services 13/06/2011 - (RMB) - risk

3
Risk Health &
needs to be clarified -review
Safety Group
next meeting
by SMT - risk remains
12/09/2011 - (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.

Monitoring
Place
3 of 6
RMB 13/06/2011 - Reduce

to 3:3. Agreed by Risk
Assessors.
Committee risk regraded
1x2=2. To be reviewed in
12 months.
Total
Sep-11
Risk Owner
Likelihood
Jun-11
Adverse impact on organisational

ADO - Integrated & 4
finances due to lack of / late recording on Community Care
CPAS resulting in financial loss.
Description
Consequence
Total
Mar-11
Risk / Hazard
Current Risk
Rating
December
Likelihood
Date added
28 January 2011
25 March 2011
612 Insuffucuent Dietetic Cover.
ID
Consequence
Source:
Incident/ RA
etc
Risk Assessment
622 Late recording on CPAS
Risk Assessment

Rating
Controls /
Actions
Required
Who
When
Review
Date
30/11/2012
9 Increase dietetic Dietetic

staffing levels for Services
RLSRH & EBH. Manager
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.
14/02/2012
Appendix B
Jun-11
Sep-11
16
16
16
16
Yearly Portable
Support Services
appliance testing (PAT) Risk Health &
in place to identify
Safety Group
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.
551 No assessment area for

Direct admissions to Farries ward of out- Associate Director 4
neutropenic patients admitted of-hours of patients presenting with
of Operations
directly to ward.
neutropenic sepsis or chemotherapy
(Medicine)
related complications. Risk occurring as
no assessment space available for these
patients.
16
16
16
12
Bed managers to
Cross Divisional
leave bed empty on
Risk Health &
Farries Ward if
Safety Group
hospital capacity
allows. 2 patients in
side rooms must be fit
to be relocated at
anytime to
accommodate this risk.
557 Agency doctors do not always

have an appropriate and
documented
handover/induction
15
15
10
10
Locum Booking
Corporate Risk
Procedure and Agency Group
Locum Booking
Procedure and
documentation.
17/08/2011 (CDRG) 4
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
08/03/2011
- Audit report
discussed(CRG)
at a meeting
on
5
has
now been completed and will
12/12/2011.
Description
Risk Owner
Domestic extension leads in a

ADO - Support
commercial environment. Failure of
Services
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 noncommercial 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
Agency doctors do not always have an

appropriate and documented
handover/induction when undertaking
locum shifts because there is noncompliance 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.
Director of HR
4 of 6
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 Board
28/06/2011 (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.
Controls /
Actions
Required
Total
Total
Mar-11
Risk / Hazard
Likelihood
Likelihood
ID
Consequence
Consequence
29 March 2011
583 Failure of electrical supply to

equipment, including
overheating
Date added

Monitoring
Place
30 June 2010
Current Risk
Rating
December
23 August 2010
Audit
Incident Report
Source:
Incident/ RA
etc

Rating
Who
When
Review
Date
12/06/2012
12
15/02/2012
10
07/02/2012
Appendix B
16
16
Staffing- Maternity Unit. Birthrate Plus,

Head of Midwifery 5
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
15
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.
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.
15
Preparations of solution - risk of skin and Associate Director 5

eye contact, risk of inhalation of fumes,
of Operations
spillage, incorrect formula for preparation, (Surgery)
storage of solution when prepared,
COSHH regulations not adhered to,
insufficient spillage kits available, lack of
procedure.
15
Serious hazard of transfusion due to lack Director of Nursing 5

of competency assessment of staff
involved in transfusion process
15
10
10
Controls /
Actions
Required
Total
Risk Owner
Likelihood
Description
Consequence
Sep-11

Monitoring
Place
Jun-11
Total
Current Risk
Rating
December
Mar-11
Risk / Hazard
Likelihood
ID
Consequence
Date added
Source:
Incident/ RA
etc

Rating
Who
When
Review
Date
Division Alert
21 June 2007
161 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.
COSHH
02 October 2007
229 Storage, usage and

preparation of Concentrated
Formaldehyde solution (40%)/
Formal saline(10%)
02 October 2008
8 Staffing- Maternity Unit
NPSA
09 October 2006
13 October 2009
RISK REGISTER 2011 - 2012 Accepted Risks

575 Failure of complete nurse call Failure of complete nurse call system &
ADO - Support
system
unavailability of a stand-by wireless
Services
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
339 NPSA Safer Practice notice

14- ability to assess
competence -2
Director of
Development
Support Services 12/09/2011 - (RMB) - Risk

Risk Health &
accepted, to be reviewed at
Safety Group
quarter 4 Risk Management
Board meeting.
General
Manager Estates
12/03/2012
13/12/2010 (RMB) - Board

has agreed to review. Risk
remains the same.
3/2/2012
2 year ongoing
Corporate Risk
programme.
Group
Audit and PAT Testing.
11/01/2011 (CRG) - Risk accepted.

Review in 12 months time.
3/12/2011
Current procedure for Cross Divisional

spillages exists.1.
Risk Health &
Training occurs for
Safety Group
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 3

Risk Group - Risk is being
managed by department.
Risk score remains the
same.
15/02/2012
10
Self assessment 'on line'

electronic transfusion
training package 'ORAS'
available within the Trust.
Annual Mandatory
transfusion training
commenced July 2008
5 of 6
Maternity Risk
Management
Group
Corporate Risk
Group

Review in 12 months time.
10
2/7/2012
Appendix B
15
10
10
10
Work carried out to previous

HTM.
New audit in progress to
new HTM.
Lack of storage has caused the hallways Head of Midwifery 5

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.
15
There are no control

Maternity Risk
measures except the Management
awareness of staff to Group
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.

Monitoring
Place
6 of 6
Corporate Risk
Group
Total
Sep-11
Risk Owner
Likelihood
Jun-11
Description
Consequence
Total
Mar-11
29 June 2009
492 SCBU corridors used for

storage
Risk / Hazard
Likelihood
Date added
08 May 2009
366 Non-compliance with

The Trust may be non-compliant to
Director of
Electrical Safety (low voltage) statutory standard relating to electrical
Development
statutory standard
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.
ID
Current Risk
Rating
December
Consequence
Source:
Incident/ RA
etc
Statutory Standards

Rating
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.
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.
10
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.
Controls /
Actions
Required
Who
When
Review
Date
2/7/2012
02/03/2012

984 Board Assurance Frameworkand Risk Quarterly Report Enclosure Tii 45

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

984 Board Assurance Frameworkand Risk Quarterly Report Enclosure Tii 45

Uploaded by

Copyright:

Available Formats

Appendix B

South Warwickshire NHS Foundation Trust Risk Register

1. One nurse per day

Children's speech and language therapy

RMB 13/06/2011 - Reduce 2

Control Measures / Person / Group

Outcome from meeting

Lack of staff capacity due to increased

Initial Risk Current Totals

614 Reduced staffing levels Leamington District Nurses.

620 Clinical treatment reduction

Collated by Joanne Beales, Risk Manager - 13 January 2012

South Warwickshire NHS Foundation Trust Risk Register

Increase in patient referrals to SLT Stroke General Manager - 4

Collated by Joanne Beales, Risk Manager - 13 January 2012

Lack of security on door leading to

Trust wide capacity issues impacting on Manager A&E

621 Increased Referrals

618 Staff security - Bedworth

629 Trust wide capacity issues

Initial Risk Current Totals

This risk replaces Risk #

Sign post at the base

Support Services 06/12/2011 - (RMB) - Health

16 Fix a digi lock to General

1. Priority for patients

Control Measures / Person / Group

Outcome from meeting

RMB 13/06/2011 - Awaiting

South Warwickshire NHS Foundation Trust Risk Register

Insufficient dietetic cover at RLSRH ADO - Support

Support Services 13/06/2011 - (RMB) - risk

Collated by Joanne Beales, Risk Manager - 13 January 2012

Control Measures / Person / Group

Outcome from meeting

RMB 13/06/2011 - Reduce

Adverse impact on organisational

612 Insuffucuent Dietetic Cover.

622 Late recording on CPAS

Initial Risk Current Totals

9 Increase dietetic Dietetic

South Warwickshire NHS Foundation Trust Risk Register

06/12/2011 - (RMB) - Risk

551 No assessment area for

557 Agency doctors do not always

Domestic extension leads in a

Agency doctors do not always have an

Collated by Joanne Beales, Risk Manager - 13 January 2012

Outcome from meeting

583 Failure of electrical supply to

Control Measures / Person / Group

Initial Risk Current Totals

South Warwickshire NHS Foundation Trust Risk Register

Staffing- Maternity Unit. Birthrate Plus,

The use of Domestic type extension

Preparations of solution - risk of skin and Associate Director 5

Serious hazard of transfusion due to lack Director of Nursing 5

Outcome from meeting

Control Measures / Person / Group

Initial Risk Current Totals

161 The use of Domestic type

229 Storage, usage and

8 Staffing- Maternity Unit