Appendix 1 Risk Register summary report, all risks as at 21.07.16 1

90 Pages·2016·1.43 MB·English

by  Information Services

Appendix 1 Risk Register summary report, all risks as at 21.07.16
ID Specialty Directorate Date of Description of the risk Existing controls in place Likelihood Consequ Rating Action plan Progress Due date Done date Likelihood Consequ Rating Likelihood Consequ Rating Director
assessment (initial) ence (initial) (current) ence (current) (Target) ence (Target)
(initial) (current) (Target)
907Corporate Corporate 14-Jan-2014 As a result of not using non-framework nursing The Trust continues to use non 5 - Very 4 - Major 20 • In-depth report to be undertaken , report complete and presented to nursing 13-Jan-2014 13-May-2014 5 - Very 2 - Minor 10 2 - Unlikely 2 - Minor 4 Director of
agencies, there is a risk that patient safety will be framework agencies and there is Likely identifying high use areas including workforce planning group Likely Nursing
compromised as we will be unable to maintain safe a separate risk assessment specialties and shift patterns of use
levels of staffing on some of our nursing wards. identifying the risk associated – to enable decisions regarding the
with this non framework use. (cid:13) reduction and ultimate end to non -
Temporary staffing policy (cid:13) framework use .
Nurse Rostering policy(cid:13)
Nurse Staffing Escalation Policy
Agree a time scale to reduce the 08/05/15 (JL) Thornbury Agency ceased 11-Feb-3014 14-May-2015
agency usage, based on for general wards. Agency useage
information from the report . monitored via nursing and midwifery
workforce planning group monthly.
Robust authorisation process in place for
non-framework Agencies.(cid:13)
Staffing solutions have a robust quality
checking process for nurses from
agencies including non-framework.
Excluding Thornbury Agency which has
its own level,quality standards which do
not comply with the Trust.
Review of the current agency contract has been reviewed and new 31-Mar-2014 13-May-2014
contract in use through the BBWG primary supplier status assigned to
framework – amendments to be meridian and cromwell
made to primary and secondary
supplier status to facilitate
maximum supply from these
approved agencies
Ensure current RUH nursing bank 31-Mar-2014 29-Jan-2016
pay rates to ensure competitive in
the local area.(cid:13)
Monitor Agency rules now apply
(Oct 2015) and processes have
been put into place to manage
booking and authorisation of
booking all Agencies including
those which are Non-framework
and outside of Monitor Agency
price caps.(cid:13)
Bank staff are now paid fortnightly
(Jan 2016) instead of monthly to
incentivise them to work and be
paid more promptly.(cid:13)
There are very good control
measures in place and mitigating
actions to support recruitment and
reduce reliance on Agency nursing
staff eg Recruitment and Retention
Group Action PLan.
Nursing recruitment campaign – to 03/06/2014 17 wte x Portuguese RNs 30-Jun-2014 14-May-2015
ensure Nursing vacancies are recruited (start date circa July 2014; 12
minimal – develop robust nursing wte x Return to Acute programme
workforce plan. agreed and commecnes Sept 2014;
business case under development for
ongoing Open Days(cid:13)
14/05/15 (JL) Recruitment and rentention
group action plan in place and monitored
through nursing and midwifery workforce
planning group. On-going but robust
process in place.
1
Appendix 1 Risk Register summary report, all risks as at 21.07.16
ID Specialty Directorate Date of Description of the risk Existing controls in place Likelihood Consequ Rating Action plan Progress Due date Done date Likelihood Consequ Rating Likelihood Consequ Rating Director
assessment (initial) ence (initial) (current) ence (current) (Target) ence (Target)
(initial) (current) (Target)
1107Paediatrics Women and 28-Apr-2015 As a result of the Wiltshire Children's services We did attempt to SLA into wilts, 5 - Very 4 - Major 20 Continue to try and influence Awaiting outcome of meeting to discuss 31-May-2015 12-Jun-2015 3 - Possible 3 - 9 4 - Likely) 2 - Minor 8
Children tender in August 2015 (new provider in place April to mitigate risk, however Likely potential providers with the aim of sub-contracting planned for May Moderate
2016) there is a risk that Children's therapies following discussions with VC this RUH thersapists being 2015.SOMPAR now no longer in the
services will be unable to cover ward in-patients has already become problematic subcontracted. Met with Sirona tender process therefore subcontracting
and some of the BANES caseload. This may and we will be loosing all wilts multiple meetings, last 14/4/15. no longer an option at present.
result in an inadequate service for in-patients and therapists to a community Meeting with Sompar planned for November 2015 -Virgin Healthcare willing
BaNES out-patients and community caseloads in location and splitting the skills. early May 2015. to negotiate subcontracting Physio
the BaNES area Therefore the risk of the same sessions from RUH. Currently under
occuring post Banes tender has discussion with Jocelyn Foster.(cid:13)
increased, and in the meantime
added pressure to banes team
has occured. The current
mitigation includes EG drawing
up a workforce plan for complete
seperation W and B teams, this
includes a small cost pressure to
the division but maintains ward
cover. It is not an option to cover
from adults due to both funding
or skill mix. This is will be
processed through 16/17 budget
setting and ITR.(cid:13)
Discussions have commenced re
Banes, and EG as instructed by
Bernie Marden is writing a
workforce requirements proposal
for both NICU and ward in light of
potential Banes moves.Adequacy
of controls dependent upon final
budget setting for 17/18.In year
ward cover is maintained by
Banes team.Any gaps in cover
due to the limitations of a Banes Meeting with adult therapy lead to EG to arrange meeting with Gina 31-May-2015 18-Jun-2015
discuss potential cross-cover of Sargeant(cid:13)
paediatric in-patients by adult Meeting booked for June 18th. Actions
service. from meeting:(cid:13)
- agreed that adult therapy staff will
provide emergency cover when no
available paediatric staff. This would be
for priority discharges or acute
respiratory problems only.(cid:13)
-to add an additional risk on datix
regarding impact of reduced staff levels
for the ward currently and with TUPE.(cid:13)
- paediatric team to offer dates for SIM
training over a 6 month period for the
adult respiratory team to improve
confidence and competence to cover the
childrens ward. 30/11/15- met with Gina
and Two band 7 adult resp physios - SIM
training successful but now saying adult
services unable to cover children`s ward
in the week and bleep only service at
weekend. Staff not happy to even provide
bleep only service due to low confidence
with paeds.No solution agreed at this
point.
Contingency plan for reduced staff Awaiting outcome of tendering process 1-Mar-2016 10-Mar-2016
available for BANES special before plan can be put into place.
schools and BANES caseload in Meeting with BANES commissioner and
event of a TUPE. BANES special school heads to advise
what core sevices will be provided and
whether schools will choose to buy in
extra services.Meetings with Virgin
Healthcare over November/December to
establish how the service will have
continuity and who will provide the
staffing.Dates to be confirmed.14/01/16
Arrangements to TUPE OT staff and
subcontract PT staff underway but not
finalised. This should resolve how special
schools are staffed.Head of Larkrise met
with 13/1/16 and reassured.Emails to
Heads of Rowdeford and St.Nicholas
schools to follow.
2
Appendix 1 Risk Register summary report, all risks as at 21.07.16
ID Specialty Directorate Date of Description of the risk Existing controls in place Likelihood Consequ Rating Action plan Progress Due date Done date Likelihood Consequ Rating Likelihood Consequ Rating Director
assessment (initial) ence (initial) (current) ence (current) (Target) ence (Target)
(initial) (current) (Target)
Costing the service to provide EG to establish cost of current service 29-Jul-2016
children's therapies to RUH- provision so that adequate cover can
based clinics e.g. NICU continue.(cid:13)
development folow-up clinic. 10/9/15 - awaiting annual casload figures
and time being collated by member of the
team.(cid:13)
18/9/15 figures sent to finance for costing
of service provision. Finance officer away
until 29/9/15 therefore unable to progress
this further at present. Costing
complete.Awaiting meeting with Virgin
healthcare to discusscontinuing input to
service. Meeting with Dr Marden to
discuss arranged 3/12/15.Meeting
rescheduled for 16/12/15. Agreed whole
NICU service needed costing and tariffs
for medical input reviewing.E-mail sent
5/1/16 by Dr Marden to request tariff and
cross charging data from becky ferris
and Kelly Jupp.NICU work being flagged
as part of subcontract with Virgincare.
Plan from Virgin Care is to revisit how
this service will continue sometime in the
next 6 months(cid:13)
4/7/16 NICU service now agreed as RUH
business. NICU SLA written and agreed
by Dr Marden -as yet to be signed
off.Cost of OT from Virgin to be
rechecked by Liz Hill and then discussed
at paeds SLM
1290Emergency Medical 13-Jan-2016 Access block and overcrowding results in a poorer 1) Emergency Department 5 - Very 4 - Major 20 Implementation of the Emergency Queuing Out process in place 1-Feb-2016 1-Feb-2016 5 - Very 4 - Major 20 3 - Possible 2 - Minor 6 Chief
Department Division Emergency Department process of care leading to guidance on "queueing out" to Likely Department Queuing Out Guidance Likely Operating
(according to international studies):(cid:13) manage clinical risk of patients Officer
1) Increased mortality and morbidity due to:(cid:13) not being assessed in the queue
- Delayed care(cid:13) in(cid:13)
- Delayed interventions(cid:13) 2) Emergency Physician In
- Increase in adverse incidents especially Charge (EPIC) - late shift(cid:13)
medication errors(cid:13) 3) Flow assistants - late shift(cid:13)
- Communication errors(cid:13) 4) Trust escalation policy(cid:13)
2) Poor effects on patient dignity and privacy as 5) Standard operating protocols
ED is designed to facilitate access and movement for inpatient admitting teams(cid:13)
and not designed for a prolonged stay(cid:13) 6) Professional standards
3) ED staff delivering inpatient care impacts on the response time with acute
delivery of care to all ED patients especially as the medicine
ED and its staff are not designed or equipped for
this(cid:13)
4) Increased staff stress and reduced staff
satisfaction(cid:13)
5) Degraded service availability and performance
resulting in prolonged waiting times and an
increase in "Did not Wait" patients who may suffer
a worse outcome in the long-term(cid:13)
6) A reduction in the quality of training for ED staff.
(Linked to risk ID: 634)
1) Professional Response In place for acute medicine and OPU 1-Apr-2016 12-Apr-2016
Standards agreed with Acute
Medicine and Geriatricians (cid:13)
(cid:13)
2) Urgent Care Collaborative Board
approved specialty response time
of 60 minutes 02/03/16 meeting -
this now requires dissemination to
the relevant divisional boards,
agree start date and monitoring
through ED Patient First system.
Delivery of workstreams within 12.04.16 - actions ongoing. 1-Aug-2016
Urgent Care Improvement Plan
(Front Door, Specialties, Discharge
Programme) to improve:(cid:13)
- Admission avoidance at the front
door(cid:13)
- Flow through inpatient wards(cid:13)
- Reduced delay in to community
capacity
3
Appendix 1 Risk Register summary report, all risks as at 21.07.16
ID Specialty Directorate Date of Description of the risk Existing controls in place Likelihood Consequ Rating Action plan Progress Due date Done date Likelihood Consequ Rating Likelihood Consequ Rating Director
assessment (initial) ence (initial) (current) ence (current) (Target) ence (Target)
(initial) (current) (Target)
1283Corporate Corporate 22-Feb-2016 As a result of the Registered Nurse workforce 1. RUH Nurse Bank, Pool and 4 - Likely) 4 - Major 16 To recruit and retain Registered Recruitment and Retention Action Plan in 27-Feb-2017 4 - Likely) 4 - Major 16 2 - Unlikely 3 - 6 Director of
vacancies across the Trust, which numbers over Agency (Framework)booking to Nurses and fill to all budgeted place.(cid:13) Moderate Nursing
100 whole time equivalent (WTE) staff despite cover gaps.(cid:13) vacancies, particularly on Wards. Recruitment and Retention Nurse post
many recruitment initiatives, combined with the 2. Ward Nurse staffing funded and post being re-advertised.(cid:13)
Monitor Agency rules (Framework) limiting the monitoring and deployments shift Nursing staff made aware of investment
availability of Agency staff, there is a risk that the by shift with Matrons and 'RAG' in nursing and also what recruitment is in
resulting deficit of nursing skills and experience to rated planned vs actual staffing place to support them (Staff news Feb
care for patients, which may result in suboptimal deployment Board to support 2016).
patient care. safe staffing levels Divisionally
and across the Trust.(cid:13)
3. Nurse staffing Escaltion
Policy.(cid:13)
4. Recruitment and Retention
Group Action Plan(cid:13)
Workforce Development and new
roles and ways of working eg
developing Assistant Practitioner
role (Band 4) to support the
nursing teams on wards.
To ensure that systems and We comply with NQB and NICE 29-Apr-2016
processes are in place to ensure guidance with regard to Safe Staffing.(cid:13)
we comply with safe nurse staffing Nurse Staffing Escalation Policy in
on the wards. place.(cid:13)
Matrons review staffing every day, shift
by shift.
1330 Corporate 15-Apr-2016 The CCGs have issued performance notices Discussions are ongoing as 4 - Likely) 4 - Major 16 Trust to feedback to CGGs on 7-Jul-2016 4 - Likely) 4 - Major 16 1 - Rare 2 - Minor 2 Chief
against the Trust's failure to deliver constitutional follows:(cid:13) proposed process for assessing Operating
targets (RTT, A&E 4hr, Diagnostics and Breast - 4hr A&E RAP - escalated to Trust performance against RAP Officer
cancer 2 week wait targets). The RUH and CCGs executive discussions(cid:13) and decision tree for imposing
are required to agree a remedial action plan for - RTT - ongoing discussion sanctions in the event of
each failed target, including an improvement between Planning&Contracting performance failure. Feedback to
trajectory; however, the trajectories and teams and Divisional Manager be provided in time for discussion
associated remedial action plans (including the (Surgery)) at RUH and CCGs at next A&E RAP meeting with
imposition of sanctions) for RTT and 4hr A&E CCGs (7 July 2016).(cid:13)
target performance cannot be agreed with This process can then be adapted
commissioners. If the remedial action plans are for use in RTT and Diagnostic
not agreed, this may result in increased regulatory RAPs.
involvement and oversight and financial penalties.
Trust to agree a process with 7-Jul-2016 7-Jul-2016
CCGs for assessing Trust
performance against RAP and
decision tree for imposing
sanctions in the event of
performance failure.(cid:13)
UPDATE - 7/7/2016 - As Trust has
agreed to participate in the
Sustainability and Transformation
Fund initiative it was agreed with
CCGs that sanctions would no
longer be imposed (as per national
guidance), so it is now no longer
necessary to agree a sanctions
regime for the RAP.
Trust and CCG to agree process 7-Jul-2016 6-Jul-2016
for assessing Trust performance
against agreed trajectory and
action plan, and for imposing
sanctions in the event of
performance failure.(cid:13)
UPDATE 6/7/16 - Agreed with
CCG that as the Trust has agreed
to participate in the sustainability
and transformation fund, guidance
now stipulates that sanctions will
not be imposed, so it is
unnecessary to agree a sanctions
procedure.
1352 Quality and 10-Jun-2016 Following last year’s increased incidence of 1. Peer review action plan which 4 - Likely) 4 - Major 16 Completion of the C diff peer 31-Mar-2017 19-Jul-2016 4 - Likely) 4 - Major 16 3 - Possible 3 - 9 Director of
Patient Safety Clostridium difficile infection there is a risk that the is monitored through the Infection review action plan. Moderate Nursing
annual target will not be achieved in 2016/17, Prevention and Control
which may result in harm to patients, as well as Committee.(cid:13)
commissioner and regulatory body concerns, 2. Antibiotic stewardship and
resulting in financial penalties. revised prescribing guidelines.(cid:13)
3. Isolation within 2 hours where
possible. Documentation of
reasons for not isolating, e.g.
side room unavailable.(cid:13)
4. Prompt stool sampling
4
Appendix 1 Risk Register summary report, all risks as at 21.07.16
ID Specialty Directorate Date of Description of the risk Existing controls in place Likelihood Consequ Rating Action plan Progress Due date Done date Likelihood Consequ Rating Likelihood Consequ Rating Director
assessment (initial) ence (initial) (current) ence (current) (Target) ence (Target)
(initial) (current) (Target)
1214Radiology Medical 2-Oct-2015 As a result of delayed replacement programmes When one CT scanner breaks 4 - Likely) 4 - Major 16 Replacement of both CT scanners 01.12.15: The Business case has been 30-Sep-2016 20-Apr-2016 4 - Likely) 3 - 12 1 - Rare 2 - Minor 2 Chief
Division for CT 1 & CT 2 scanners, both of which are in down, the other scanner is used through a business Case for submitted to the Management Board and Moderate Operating
excess of seven years old, there is a risk that the for urgent patients. However, this funding. will go to the Board of Directors in Officer
resulting increased amount of downtime for repairs creates a backlog of out-patient January 2016. The replacement of both
would lead to a failure of the Trust to meet the six scans and results in breaches for scanners (sequentially) has been
week diagnostic targets and the two week cancer cancer targets as well as included in this over-arching business
targets, which may result in financial penalties and diagnostic targets. If both case. 20.04.16 - BC was approved and
a loss of reputation. scanners break down - urgent funding secured for CT replacements.
patients are re-routed to Bristol. This action is complete and the risk
We also have the occasional score reduced to 12 to reflect this action
scanner visiting on a mobile van. closure.
In the event of breakdown, there
is a lack of facilities at the RUH
site to accommodate more than
one van at a time and the MRI
van would ave to be displaced to
allow for a CT van.
Installation and completion of the 01.12.15: PET CT project due to be 30-Jun-2016 6-Jul-2016
Positron emission tomography completed in June 2016(cid:13)
(PET) CT project, this will allow Update (SB) 06.07.16: Scanner up and
some CT capacity whilst the running - staff training on going
existing CT scanners are replaced
sequentially.
Head of Radiology to seek 01.12.15: Site visits have already taken 30-Sep-2016
agreement from the Clinical place for replacement equipment and
prioritisation management group equipment identified on the national
regarding the replacement of the framework.Update July 2016 (SB): One
first CT scanner as a matter of scanner is due to be replaced by the end
urgency. of 2016 (PET CT needs to be fully
functional and staff trained in order for
this to be the second CT whilst
replcement occurs). Second CT to be
replaced at the beginning of 2017 when
the first is installed and working at full
capacity.
1215Estates Water Estates and 9-Nov-2015 As a result of the recent death of a patient 1. Managing the press coverage 4 - Likely) 4 - Major 16 Complete all required actions 31-Dec-2015 4-Jan-2016 4 - Likely) 4 - Major 16 2 - Unlikely 4 - Major 8 Director of
Facilities following Legionella pneumoehila pneumonia, there of the Coroner's Inquest;(cid:13) identified in the previous 2007 Estates &
is a risk that the Trust will be prosecuted by the 2. Approaching authorising prosecution report and provide Facilities
Health & Safety Executive, which may result in engineer to assist in the RCA evidence to the Board of Directors.
extremely poor press coverage and impact upon investigation report;(cid:13)
the reputation of the Trust. 3. All staff involved have received
a briefing from the Trust
Communications team.(cid:13)
4. The Trust Solicitors have been
engaged in the process.
To implement actions for all areas 31-Dec-2015 4-Jan-2016
of improvement identifiedby the
Trust's independent authorising
engineer, in the audits undertaken
in 2014 & June 2015.
Promptly comply with the 8-Jan-2016 4-Jan-2016
improvement notice issued by the
HSE in August 2015.
Prepare for the Coroner's inquest, 31-Dec-2015 4-Jan-2016
scheduled for early February, with
support from the Trust's legal
services team at Bevan Brittan.
1219Clinical Operations 25-Apr-2016 On the 26th & 27th of April 2016 from 0800 -1700, Extensive planning to ensure that 4 - Likely) 4 - Major 16 Undertake a preparatory scoping Completed 27-Nov-2015 27-Nov-2015 3 - Possible 4 - Major 12 3 - Possible 3 - 9 Chief
Divisions there will be a full withdrawal of labour by Junior the Trust's critical activities are activity to identify those services Moderate Operating
Doctors, including emergency care, as part of their maintained to a safe standard. that may be impacted, by means of Officer
on-going Industrial Action. This is the first Planning has included working completion of the DoH assurance
Industrial Action of this kind in NHS history and as closely with external stakeholders template.
such there is a risk that patient care will be to ensure the Trust is well
affected. supported. On the days of action,
Silver and Gold Command and
Control will be in place linked with
local CCGs. See Action Plan for
breakdown of mitigations.
Available staff have been 25-Apr-2016 25-Apr-2016
reallocated on the days of action to
ensure that all emergency
pathways are maintained. Critical
services such as the Emergency
Department, Critical Care and the
Resus Team will be provided
throughout the industrial action. A
framework is in place to ensure that
access to specialist services is
maintained.
5
Appendix 1 Risk Register summary report, all risks as at 21.07.16
ID Specialty Directorate Date of Description of the risk Existing controls in place Likelihood Consequ Rating Action plan Progress Due date Done date Likelihood Consequ Rating Likelihood Consequ Rating Director
assessment (initial) ence (initial) (current) ence (current) (Target) ence (Target)
(initial) (current) (Target)
A number of outpatient Completed 25-Apr-2016 25-Apr-2016
appointments and elective
surgeries have been cancelled due
to the full walk out of Junior
Doctors and the subsequent
reduction in workforce.
A comprehensive communciations Completed 25-Apr-2016 25-Apr-2016
plan has been created and followed
to ensure that both internal and
external stakeholders are informed
about the forthcoming industrial
action in a timely manner.
The Trust has been linking closely Completed. 25-Apr-2016 25-Apr-2016
with external stakeholders to
ensure that the local health
economy is engaged with our
Industrial Action pre-planning &
response. The wider system are
supporting the Trust with a 4 day
period of focus on de-escalating
the RUH with additional resources
and re-allocation of staff to reduce
admission numbers and increase
discharges. External stakeholders
will be updated as appropriate
throughout the 2 day period.
During the period of Industrial 29-Apr-2016
Action, a full command and control
structure will be set up with Silver
(Tactical) and Gold (Strategic)
commands. Silver Command will
be in situ throughout the industrial
action period (for extended hours)
with regular meetings x3 daily. Gold
will hold a teleconference to update
external stakeholders at strategic
level on a daily basis and will be
available to response internally
throughout both days.
Strike Line (5509) and Green Line 28-Apr-2016
(1132) will be set up throughout the
Industrial Action period to give staff
access to immediate advice and
support on operational and strike
related issues.
Support is required from 28-Apr-2016
departments such as IT and
Pharmacy throughout the Industrial
Action period. These departments
have been engaged in the pre-
planning as appropriate and will
form part of Silver command on the
days of action.
1237Theatres Surgical 31-Dec-2015 As a result of the recent Surgical Site Surveillance A multi-disciplinary team has 4 - Likely) 4 - Major 16 To establish regular meeting wtih Initial meeting held in December 2015 31-Dec-2015 31-Dec-2015 4 - Likely) 3 - 12 2 - Unlikely 4 - Major 8 Chief
Division Reports and internal audits of unplanned returns to reviewed all possible contributary Estates team to review the Moderate Operating
theatre, which highlighted the RUH as a potential factors including:(cid:13) following:(cid:13) Officer
outlier status in relation to the incidence of - Staff involved in each case(cid:13) - Existing environmental concerns
infections over the past 3 quarters, there is a risk - Peri-operative practice including (cid:13)
that the theatre environment is a cause of surgical skin prep, antibiotic compliance, - Urgent refurbishment / repairs
site infections to patients, which may resulting theatre etiquette and surgical required(cid:13)
litigation. instrumentation(cid:13) - Prioritisation of works(cid:13)
- Environmental issues(cid:13) - Review of any external audits or
(cid:13) reports(cid:13)
At this time it is assess that - Formal sign off process (included
environmental issues may have in risk 406) to ensure appropriate
played a significant part and a full risk management as issues arise
maintenance programme has
been initiated.
To maintain regular multi- Action plan reviewed monthly at the 18-Jul-2016
disciplinary review of any infections SSISG meeting
potentially associated to peri-
operative care to include unplanned
returns to theatre associated with
infection or unforeseen washout
and national SSIS data reports.
6
Appendix 1 Risk Register summary report, all risks as at 21.07.16
ID Specialty Directorate Date of Description of the risk Existing controls in place Likelihood Consequ Rating Action plan Progress Due date Done date Likelihood Consequ Rating Likelihood Consequ Rating Director
assessment (initial) ence (initial) (current) ence (current) (Target) ence (Target)
(initial) (current) (Target)
1238Neurology Medical 12-Jan-2016 As a result of the current negotiations with the c.(cid:9)The current actions for this 4 - Likely) 4 - Major 16 Have regular monthly meetings Meetings Ongoing 30-Sep-2016 4 - Likely) 3 - 12 3 - Possible 3 - 9 Chief
Division commissioners to continue funding for the Post- risk are within both the Trauma with the following stakeholders to Moderate Moderate Operating
Acute Neuro Trauma Service on Helena ward, Meeting agenda chaired by review funding progress Officer
there is a risk that on-going funding may not be Richard Graham and the Med
obtained, which may result in the ward being divisional Helena meetings
unable to take the early ITU transfer patients and it chaired by both Fiona Bird and
being unsafe to repatriate these trauma pathway myself.(cid:13)
patients. d. At the last meeting it was
confirmed that the Finance team
are currently in liasion with
Specialised commisioning, the
RUH senior team have agreed
to continue the Helena ward
Rehab team for a further 6
months and billing spec comm
accordingly. The team are also
continuing to raise the rehab
issue with spec comminssioning
and NHS England.(cid:13)
March 2016 - Currently we have
actions in place to manage the
risk with short term agrreement
to continue the servce while
discussions with spec
commisioning are ongoing.
Ensure a formal NHS England / 30-Sep-2016
Specialist Review of the service
occurs either in isolation or as part
of wider network review
1274Estates Building Estates and 19-Feb-2016 As a result of the HSE not providing the Trust with Improvement notices have been 4 - Likely) 4 - Major 16 Maintain contact with the Trust On-going. Awaiting feedback from the 31-Mar-2017 4 - Likely) 4 - Major 16 3 - Possible 3 - 9 Director of
Facilities a clear decision on how they plan to proceed with complied with. The Trust has a solicitor regarding any information HSE Moderate Estates &
regard to the patient's fall from height in 2012, suite of window risk or preparation required. Facilities
there is a risk that contracts and tenders may be assessments. PPM schedule in
adversely affected by the fact the Trust is being place to check windows and
investigated.(cid:13) restrictors annually. Trust's legal
A prosecution could result in a significant fine advisors have requested regular
following changes to sentencing guidelines, which updates from the HSE, and have
could adversely affect the reputation of the Trust advised that a substantial fine
following the publicity generated after such a isn't in the public's best interests.
prosecution.
1064Radiology Medical 10-Feb-2015 As a result of the low numbers of interventional Ad hoc rota in place. 4 - Likely) 4 - Major 16 Radiology to provide a new Nurse consultation complete. Nursing 31-Jul-2016 2 - Unlikely 3 - 6 2 - Unlikely 3 - 6 Chief
Division radiologists and interventional radiology specialist radiologist rota to ensure additional staff begin a pilot system to provide ad Moderate Moderate Operating
nurses, there is not a 24/7 provision of cover supported by consultation hoc cover to rostered interventional Officer
interventional radiology at the RUH.(cid:13) with the radiology nurses radiologists. Rota has yet to be actioned
There is a risk that patients may not be able to by radiologist staff. Nurse consultation
receive emergency interventional radiology considered only existing incidence of
procedures in a timely manner. This may result in interventional cover and does not
a threat to life.(cid:13) consider more robust working
Those exposed to the risk are, patients, staff and patterns.Update 02/06/15 - Further
the organisation. meeting held on 2 June and a suggestion
that cardiology Nurses who are already
on call should be consulted on providing
cover(cid:13)
2/7/15. Cardiology nurse cover is being
costed up.(cid:13)
29.07.15 - following radiology CG
meeting - CF reported that cardiology
nurses option is looking unlikely and that
we will probably have to continue with the
ad-hoc service that runs at the
moment.(cid:13)
New radiologist 1 in 5 rota starts 4 Jan
16 with continued nurse ad hoc support
until business case approved at Jan 16
MB(cid:13)
Update July 2016 (SB)Nursing vacancy
(2.4WTE) about to go out to advert to
cover recovery room rota as well as help
to implement OoH's cover for
nephrostomies.
7
Appendix 1 Risk Register summary report, all risks as at 21.07.16
ID Specialty Directorate Date of Description of the risk Existing controls in place Likelihood Consequ Rating Action plan Progress Due date Done date Likelihood Consequ Rating Likelihood Consequ Rating Director
assessment (initial) ence (initial) (current) ence (current) (Target) ence (Target)
(initial) (current) (Target)
Development of SLA with NBT for Update 14.05.15: Documented clinical 29-Jan-2016 12-Apr-2016
referral of patients to Bristol pathway needed and not an SLA. David
McClay has discussed this with Fiona
Bird and is not the correct person for the
action. This has been amended and
another date assigned.(cid:13)
(cid:13)
21.10.15 - pending development of RUH
service model.(cid:13)
(cid:13)
06.12.2015 - business case presented to
Mgmt Board in November - to go to
BoD.(cid:13)
(cid:13)
12.04.16 No longer required for this
element of the service as the business
case has been signed off. See risk 1263
for specialist work issues.
Fiona & Craig to arrange a meeting Update 20.05.15 - CF & FB have met 29-Jan-2016
with NBT counterparts to formalise with NBT, awaiting outcome of the
process for transferring out of meeting.(cid:13)
hours urgent cases requiring (cid:13)
interventional radiology support. 04.06.2015 - information sent to NBT by
This arrangement would only be CF, response chased. Next RUH internal
required when the RUH on call meeting 16.06.15, review date amended
interventional radiology team are to reflect this (note added by FB)(cid:13)
unavailable (cid:13)
03.07.15 - James Stevenson and Craig
Forster progressing plans to use cardiac
team.(cid:13)
(cid:13)
21.10.15 - pending development of RUH
service(cid:13)
(cid:13)
06.12.2015 - BC presented to November
Mgmt Board, for BoD.(cid:13)
(cid:13)
Update July 2016: Dr Dom Fay to meet
with Medical director to decide how to
progress the issue of NBT helping with
this situation OoH's radiologist cover. No
agreement to date, therefore risk score
remains the same
Clarify position with int radiology 03.07.15. Plan to use cardiac nursing 29-Jan-2016 1-Jan-2016
team with regards to extra payment team being progessed by James
required to establish a 24/7 on call Stevenson and Craig Forster.(cid:13)
rota. (cid:13)
06.12.2015. Staffing requirements within
business case - presented to November
Mgmt Board, for presenation at BoD
next.
Feasibility study to assess whether As at 18.5.15 - theatre team have 30-Jun-2015 13-Jul-2015
theatre nurses could support the assessed feasbility of theatre nurses
out-of-hours service. Craig Forster supporting and agreed that it would be
to clarify if this is an option with the possible. Yet to confirm that theatres
radiologists would be able to release a nurse to
support a list.(cid:13)
(cid:13)
As 1t 13/7/15 - following cross divisional
discussions, the preference now is to
utilise the cardiac cath lab nursing teams,
rather than the theatre nursing teams due
to unfamiliarilty of theatre staff with
radiology procedures.
A completed risk assessment for This action is no longer required as a 10-Nov-2015 14-Jan-2016
the transfer process of patients local rota for the interventional
(assuming NBT have agreed to radiologists has now been established.
accept the transfer) with a view to
determining if a transfer is viable
and safe.
Whilst an ad hoc out-of-hours 08.01.15 - Discussed with new Clinical 31-Mar-2016 8-Feb-2016
process is almost in place for Lead at Risk register review. Plan of
urology emergency case covered action being developed.(cid:13)
by the 5 interventional consultant 03.02.16 (SB)- This risk has been
radiologists, there is very limited entered onto Datix as a separate risk
cover for emergency embolisation (number 1263) following discussion at
cases out-of-hours. This is as a divisional governance meeting.
result of only 2 out of 5
interventional Radiologists being
able to carry out these procedures.
A formal process/ system of work
needs to be agreed between the
RUH and NBT.
8
Appendix 1 Risk Register summary report, all risks as at 21.07.16
ID Specialty Directorate Date of Description of the risk Existing controls in place Likelihood Consequ Rating Action plan Progress Due date Done date Likelihood Consequ Rating Likelihood Consequ Rating Director
assessment (initial) ence (initial) (current) ence (current) (Target) ence (Target)
(initial) (current) (Target)
930Adult Quality and 21-May-2014 As a result of the change in legislation around Current DoLs training. 4 - Likely) 4 - Major 16 Amend all training plans and Review of training materials completed. 15-Feb-2015 30-Jan-2015 3 - Possible 4 - Major 12 2 - Unlikely 4 - Major 8 Director of
Safeguarding Patient Safety Deprivation of Liberty, as of March 2014; this materials to reflect new legislation Delivery plan for additional training Nursing
means that a higher number of patients will be requirements to be agreed(cid:13)
eligible for placing under a Deprivation of Liberty Additional training programmes in place
Safeguard (DoLS). The patients affected will be
those assessed as lacking capacity & meet the
Acid Test criteria-under continuous supervision &
control [i.e. are receiving 24 hour care & routines]
& are not free to leave [even if accompanied]. As
a result, there is a risk that the Trust may detain
patients illegally, because it does not have the
capacity to administer & monitor the formal
processes required.
Business case for administrator for Business case being presented to 30-Jun-2015 6-Jul-2015
DoLs helpdesk facility to support management board.(cid:13)
DoLs process as likely to have 50 Waiting on date(cid:13)
applications each week Still waiting for decision on business
case. Currently offering extra hours to
current administrator to support
demand(cid:13)
Agreement in principle from CCG for
funding, awaiting conformation(cid:13)
30/3/15. Funding for Dols administration
has been granted , however it is still
unclear if this funding is recurrent.(cid:13)
Cenntalisiation of all DoLS faxes and the
overall process is within the
Safeguarding Adults team.(cid:13)
Risks still remain due to the lack of
Qualified Best Interests Assessors.(cid:13)
There still remains a risk in lack of
knowledge in regards to when the
hospital needs to make an application to
the local authority. The outcome of this
being an unlawful deprivation of liberty.
180Infection ControlQuality and 24-Nov-2009 As a result of the inadequate isolation facilities in 1. Trust procedural documents: 4 - Likely) 4 - Major 16 The creation of additional side Closed:(cid:13) 31-Dec-2015 16-Aug-2011 4 - Likely) 4 - Major 16 2 - Unlikely 3 - 6 Director of
Patient Safety the Trust including the RNHRD site, there is a risk Infection control, hand hygiene, rooms, to increase the number Isolation strategy group report will inform Moderate Nursing
that it may not be possible to isolate patients with isolation, MRSA, Diarrhoea & from 22% to 25+% of available the capital programme.
infective diseases from other patients and vomiting, C. Diff., Outbreak, beds, as a mid term objective. By
therefore these others are vulnerable to picking up Chickenpox/Shingles, TB, means of incorporating this need in
illness they didn't already have. This is likely to Influenza, Meningitis.(cid:13) the appropriate capital
occur with conditions such as MRSA, norovirus 2. Outbreaks monitored by the programmes in an incremental
and C Difficile, but may also happen with IP&C committee(cid:13) fashion.
respiratory viruses such as flu viruses. The Trust 3. Investigation of C. Diff and
does not currently have a negative pressure MDRTB cases using RCA
isolation facility for patients with infections where methodology.(cid:13)
the outcome maybe most serious, for example, 4. IPCT provide Clinical Site
MDRTB, viral hemorrhagic fever and novel tEam with a list of patients with
infections.(cid:13) infections who are isolated
Risk agreed as tolerated by the Management Monday-Friday. Site Team will
Board. identify from the list where there
are side rooms occupied by non-
infected patients.(cid:13)
5. All wards to inform IPCT and
Clinical Site Team if there are
patients with known or suspected
infections who are not isolated.(cid:13)
6. Side room 29 (currently used
as a consulting room) on MAU to
be used as an isolation room
when there are patients who
require isolation on the ward or in
ED.
Scope the hire of isolation facilities Completed:(cid:13) 31-May-2011 20-Jun-2011
from external providers, to isolate The trial of some temporary isolation
patients in the ward environment facilities was undertaken as part of a
(these can be provided over the national feasibility study. The results of
bed space), for use in extreme the I-STRAT trial identified a wider trial
situations. was probably necessary. However the
cost indicated for the use of the screens
appears prohibitive at this time.
Cohort nursing of same sex and Closed, on-going:(cid:13) 31-Mar-2010 25-Feb-2011
illness patients. Cohort nursing advised by the infection
control team for patients with similar
infections.
9
Appendix 1 Risk Register summary report, all risks as at 21.07.16
ID Specialty Directorate Date of Description of the risk Existing controls in place Likelihood Consequ Rating Action plan Progress Due date Done date Likelihood Consequ Rating Likelihood Consequ Rating Director
assessment (initial) ence (initial) (current) ence (current) (Target) ence (Target)
(initial) (current) (Target)
Creation of an Isolation Strategy Completed:(cid:13) 31-Jul-2013 25-Jul-2011
Group, with the aim of the group is Isolations Strategy Group formed and
to identify how we can increase our options appraisal submitted to
ability to isolate/cohort patients with Management Board, outlining the action
infections within the decreasing bed plan to increase capacity & improve the
base and provide the management current facilities. Action plan
Board with an options appraisal. implementation to be monitored by the
SLIC.
186Radiology Medical 15-Mar-2010 As a result of the backlog of unreported computed 1. Demand management within 4 - Likely) 4 - Major 16 Protocols on ICE for GP requesting Completed:(cid:13) 24-Mar-2011 24-Mar-2011 3 - Possible 3 - 9 3 - Possible 1 - 3 Chief
Division tomography (CT) and magnetic resonance the specialties (consultant only to reduce demand. Currently live for GPs & IP requesting. Moderate Negligible Operating
imaging (MRI) results within the two week referral for hospital MRI and CT Officer
‘acceptable’ timescale, there is a risk that investigations).(cid:13)
abnormal pathologies will not be identified, which 2. Out sourcing to 'Medica' and
may result in increased morbidity and litigation and 'Alliance Medical'. Whilst the
delays in diagnosis.(cid:13) backlog has been significantly
Risk agreed as tolerated by the Management reduced, this is costly and a
Board. paper needs to go to the Trust
Board July 2011 (CF & GR)
Outsourcing of MRI and CT Achieved: (cid:13) 30-Apr-2010 30-Jun-2010
reporting Outsourcing in place since July 2010.
Recruitment of 2.5 WTE consultant Completed 2010 1-Jan-2011 22-Mar-2012
Radiologists
Implementing 'Nighthawk', an Achieved 31-Aug-2011 13-Oct-2011
external radiology reporting
process for OOH CT & MRI.
Revise the cap on numbers of MRI Now achieved 29-Apr-2011 29-Jul-2011
& CT needing reports before
outsourcing the reporting.
Business Case for backlog in CT/ Completed:(cid:13) 29-Sep-2011 13-Oct-2011
MRI reporting to be compiled by Business plan to go to March
Craig Forster and Graham management Board to address the
Robinson. Out sourcing expensive reported risks.
(Medica & Alliance Medical).
An additional Business Case for Complted:(cid:13) 28-Sep-2012 16-May-2012
1.5 x WTE Consultant, 2 x Fellows Management Board to consider the
& 1.5 Radiographers has been business case for additional capacity in
submitted and approved in an September 2012.
attempt to reduce the number of
images being 'out sourced' for
reporting. Whilst outsourcing is
helping with the back log in
reporting there is still a delay of 2
weeks for reports.
To review volume of outsourched 20.04.16 - BC has been approved. We 31-May-2017
reporting and Radiologists continue to outsource because we have
reporting WLI's when not finished recruiting consultants and
Consultant, Fellow's and workload is increasing. With outsourcing
Radiographer vacancies are filled we are managing to get the majority of
reporting completed within 5 days (with
the exception of some very specialist
cases on occasions). The risk score has
been reduced to reflect this.(cid:13)
Reporting radiographers in training . Not
up to speed until 2017(cid:13)
update July 2016 (SB) - score to remain
the same despite appointment of 2 x
Consultant radiologists. having to
continue with our sourcing and WLI
reporting sessions
Recruitment of additional Update July 2016 (SB): 2 x successful 1-Jul-2016 1-Jul-2016
consultant radiologists (1 x MSK appointments of consultant radiologists.
and 1 x Neuro)as per BC approval One to start in Sept 2016 and the other
to start in 2017
10