report to trust board - northern devon healthcare nhs trust · 6/3/2008 · for information. •...

Best Care, Highest Standards, Right Place

Report to Trust Board

Date 3 June 2008

Agenda Item A4

Agenda Title Risk Management Committee Minutes

Sponsor Andy Robinson, Director of Finance and Performance

Prepared by Margaret Gill, Minute Secretary Presented by Andy Robinson, Director of Finance and Performance

1 Purpose and Key Issues To present the minutes of the Risk Management Committee to the Trust Board for information. • Minutes of the meeting 20 March 2008 and 17 April 2008 • Draft minutes for the meeting held on 15 May 2008

2 Equality and Diversity Implications

The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. No adverse or positive impacts have been identified from the Committee’s actions.

3 Legal Implications Robust risk management processes enable the Trust to meet the legal requirements of the Health and Safety at Work Act (1974) and the Management of Health & Safety at Work Regulations (1999).

4 Patient, Public and Staff Involvement

Membership of the Risk Management Committee includes staff and Non-Executive Directors. The Trust’s business planning process incorporated patient and public involvement. Robust and effective financial control and risk management systems ensure that the Trust’s services can be developed and delivered to meet the needs of patients in the medium term.

5 Controls and Assurances

The minutes of the meeting are considered by the Risk Management Committee for accuracy. Following discussion, amendments may be recorded as appropriate. The minutes are then formally approved by the Committee. Copies of the Risk Management Committee minutes are presented to the Clinical Governance Committee, the Audit and Assurance Committee and to the Trust Board to note. The arrangements and actions of the Risk Management Committee are reviewed by the Audit Commission as part of the annual Auditors Local Evaluation assessment and is reported in the Annual Audit Letter. The Committee is also

Risk Management Committee Minutes Northern Devon Healthcare NHS Trust Trust Boar 3 June 2008

assessed by Internal Audit as part of the annual Head of Internal Audit Opinion based on the Chief Executive’s annual Statement on Internal Control. The Trust’s risk management arrangements have been developed to meet the requirements of the NHS Litigation Authority’s Risk Management Standards for Acute Trusts and of the Healthcare Commission’s Standards for Better Health.

6 Cost Implications There are no cost implications.

7 Potential risk to the organisation

If the minutes are not approved, the Trust will be at medium risk of not acting in accordance with the organisation’s Standing Orders. Risk score 9 (Consequence = 3 x Likelihood = 3).

8 Recommendations

The Board is asked to NOTE the minutes of the Risk Management Committee.

Corporate Affairs of 23


Strategic Objectives Ten strategic objectives were agreed by the Trust Board in May 2007 to support the Trust’s mission statement “Best Care, Highest Standards, Right Place”. The strategic objectives have been developed to ensure there is a shared understanding and common purpose throughout the organisation about the Trust’s strategic direction and what needs to be delivered.

X Patient Safety High Quality Services

Efficient & Effective Strategic Partnerships

Listening and responding to the needs of patients Modern and Effective Infrastructure

Deliver Care in the most appropriate setting Public Health

Integrate Health and Social Care X Robust and Sustainable

Standards for Better Health The Core and Developmental Standards for Better Health have been developed by the Healthcare Commission. Compliance with the Standards throughout the year form a part of the Trust’s Annual Health Check.

C1a Incident Reporting C7e Equality & Diversity C16 Patient Information

C1b Safety Alerts C8a Whistle blowing C17 Patient & Public Involvement

C2 Child Protection C8b Personal Development Programmes C18 Access to Services –

Equality & Choice

C3 NICE – Interventional procedures C9 Records Management C19 Access to Services –

Emergency care

C4a Infection Control C10a Employment Checks C20a Security and Health & Safety

C4b Medical Devices C10b Professional Codes of Conduct C20b Patient Privacy &

Confidentiality

C4c Decontamination C11a Recruitment C21 Hospital Cleanliness

C4d Medicine Management C11b Mandatory Training C22a Public Health – Health inequalities

C4e Waste Management C11c Professional Development C22b Public Health – D of

PH report

C5a NICE – Technology appraisals C12 Research & Development C22c Public Health -

Working with partners

C5b Clinical Supervision & Leadership C13a Dignity & Respect C23 Public Health – Health

promotion

C5c Clinical Professional Development C13b Consent to treatment C24 Major Incident

Planning

C5d Clinical Audit C13c Use of Confidential Information X D1 Patient Safety – Risk

reduction

C6 Healthcare bodies co-operating together C14a Complaints - Information D2a Clinical Effectiveness –

Best practice

X C7a Corporate Governance C14b Complaints – Non-discrimination D13a Public Health – Health

inequalities

X C7b Finance & Probity C14c Complaints – Service improvements D13b Public Health –

National guidance

X C7c Clinical Governance C15a Patient Food Standards

C7d Performance C15b Patient dietary requirements



RISK MANAGEMENT COMMITTEE Thursday 20 March 2008 Chichester Board Room

PRESENT :

Tony Blake IT Services Manager (TB) Annette Crew Risk & Incident Manager (AEC) Juliet Cross Head of Corporate Affairs (JFC) Alison Diamond (Chair) Associate Medical Director - Clinical

Governance (AD) Sam Jones Non-Executive Director (SJ) Pauline Lockwood Modern Matron, South Molton (PL) Bob Lowe Deputy Estates Manager (BL) Carolyn Mills Director of Nursing (CM) Janet Phipps General Manager, Women’s and Children’s

Services (JP) Caroline Raby Senior Nurse, Clinical and Support Services

(CR)

IN ATTENDANCE: Margaret Gill Minute Secretary

MINUTES

Actionee 1. Apologies

Apologies were received from:

Colin Dart Deputy Director of Finance (CD) Jo Gibbs Director of Operations (JG) Nikki Kennelly Interim Director of Community Services (NK) Mandy Kilby Clinical Governance Manager (MK) Mike Lock Planning and Performance Manager (ML) Kate Maynard Director of Development (KM) Catherine Oliver Director of Human Resources (CO) Andy Robinson Director of Finance & Performance (AR) Katharine Robinson A&E Consultant (KR) Martin Scrace Head of IM&T (MS) Bindy Sumner Staff Organisations Committee Chris Thomas Senior Nurse/Head of District Nursing (CT) Amelia Tucker-Jones Non-Executive Director (ATJ)

2. Minutes of last meeting The minutes of the meeting held on 21 February 2008 were ACCEPTED.

3. Matters Arising 3.1 3.2 - Risk ID 537 – Hip Replacements/Implants

AEC advised that the actionee should be AD. AD reported that a letter had been received from Christopher Mills who had been undertaking some scoping and benchmarking work in respect of the use of the cups and stems from different manufacturers. The Northern Devon Healthcare NHS Trust had been using mis-matched equipment but is now going to use Exeter stems and cups. It was agreed that further audit problems would be prevented if the same manufacture supplied the equipment, but AD will brief the Executive Committee on this.

AD



Actionee Action continues.

3.2 3.3 – Risk ID 473 – Patient Group Directives for use in Minor Injuries

Units not ratified for use by Northern Devon Healthcare Trust AEC reported that she had met with Fionn Bellis, a risk assessment had been completed, and a number of actions were taking place. Action closed.

3.3 3.6 - High Scoring Risks (15+) – December 2007 - Risk ID 543 – Risk of failure of piped oxygen supply to NDDH site AEC reported that she would be meeting with Paul Cooper on 24 March 2008. Action continues.

3.4 3.12 – Risk ID 485 – Risk in the use of cot sides/bed rails AEC reported that she had contacted Karen Facey. CM advised that she will be presenting a Bed Rails Policy to the next meeting of the Senior Nurse Forum. Action continues.

3.5 3.7 – Torrington Incident JFC advised that the basic draft report was completed and would shortly be circulated to the review team. Action continues.

3.6 4.1 – Terms of Reference

JFC reported that the agreed amendments had been made to the Terms of Reference and the document circulated. Action closed.

3.7 5.2 - Risk ID 576 – PAS implementation at Lynton Resource Centre

MIU AEC reported that this risk had been actioned, rescored and was now accepted. Action closed.

3.8 6.3 – Principal Risk and Assurance Register (PRAR) Risk ID 574 – Endoscopy Scopes Risk ID 575 – Provision of Orthotics – Podiatry Service Risk ID 578 – Podiatry services staffing Actionees not at meeting – to be referred to the next meeting Actions continue.

AEC

CM

JFC

Mki NK NK

4. Corporate Risk Register 4.1 Corporate Risk Register Update Report – March 2008



Actionee

AEC presented the update report dated March 2008, which summarised and updated information on New Risks, Accepted Risks and Exception reports dated March 2008.

4.2 New Risks – March 2008

AEC reported there were ten new risks, nine of which were scored at 15+. Following discussion, the Risk Management Committee: • NOTED – the New Risk Report for March 2008.

4.3 Accepted Risks – March 2008

AEC reported that 16 risks were recommended to be accepted for the month of March, where the manager of the risk had confirmed that all action plans had been completed and the risk had been rescored. Eleven of the risks recommended for acceptance had an initial score of 15+. The Risk Management Committee APPROVED the risks presented in the Accepted Risks – March 2008 Report.

4.4 Exceptions Report – March 2008

AEC reported on the exception report as at March 2008 Following discussions the Risk Management Committee: • NOTED - that 23 exceptions were recorded for the month. • NOTED – that 15 risks had amendments to action plans, due dates,

etc. • NOTED - that no response had been received from eight requests for

an update. In two cases, this was the second non-response and a letter had been sent from AR to the managers of the risks requesting an update for the RMC. Responses wee received in time.

• NOTED – Risk ID 472 – Risk associated with rain water coming through the ceiling in PA 44 (Pathology laboratory) – This risk had been ongoing prior to being raised on the Corporate Risk Register in August 2007. BL reported that he thought the problem had been rectified and would follow up the risk.

• NOTED – Risk ID 510 – Inadequate ventilation in patient shower rooms – BL reported that Capener Ward had been refurbished two years ago, since when there have been problems with some patients and staff feeling faint when in the shower room. A ventilation panel had been inserted in one door, but this had not alleviated the problem. No problem had been experienced from Staples Ward or KGV, although they were sited on the same side of the hospital. Work was being undertaken and it was hoped the problem would improve within the next two months. BL to report back to the Committee.

• NOTED – Risk ID 551 – Risk of demand for temporary staff exceeding availability – AEC reported that this risk had been reviewed by CM and five new action plans have been added.

• NOTED – Risk ID 509 – Absence of Information Governance

BL

BL



Actionee Toolkit Auditor role – AD reported that there has been progress on the availability of training through CETIS which had been a risk to the toolkit self assessment and statement of compliance. This e learning package had an audit trail of training undertaken and by whom.

• NOTED the risks presented in the Exceptions Report – March 2008 Report.

6. Principal Risk and Assurance Register 6.1 Corporate Risk Register Summary – March 2008

AEC reported on the Corporate Risk Register Summary for March 2008. Following discussions the Risk Management Committee: • NOTED – Risk ID 356 – Incorrect prescribing of Heparin; Risk ID

357 – District Nursing Service - failure to deliver – These risks had been accepted at a score of 15+, but would remain on the Corporate Risk Register Summary until any change is made to the score.

• NOTED –Risk ID 357 – District Nursing Service - failure to deliver; Risk ID 359 – District Nursing Service – unmanageable workload – AD reported that a review of the District Nursing Teams was being undertaken. CM commented that this review would not address the increased workload under QOF (Quality Outcomes Frameswork).

• NOTED – Risk ID 455 – Theatre 8 theatre bed not suitable for women weighing in excess of 133kg – JP advised that the bed had been ordered and once delivered the risk score would be amended.

• NOTED – Risk ID 462 – Failure to meet MRSA reduction target and implement Saving Lives Programme – AEC reported on an update provided by AK, which advised that the Saving Lives Programme was being implemented.

• REQUESTED – Risk ID 513 – Storage of Hand Gel – fire risk – wording to be changed to “inflammable metal lockers”, from “flammable metal lockers”.

• NOTED – Risk ID 514 – Smoking in Trust premises – The Trust is not looking to introduce designated sites for smoking, and the risk will remain on the Corporate Risk Register.

• NOTED the Corporate Risk Register Summary for March 2008.

6.2 High Scoring Risks (15+) – March 2008

AEC presented the details of the High Scoring Risks 15+ as at March 2008.

6.3 Principal Risk and Assurance Register (PRAR) – March 2008

The RMC considered nine new 15+ risks: Risk

ID Title Comment Principal Risk

585 Risk of failure to replace Harmony BIPAP nasal ventilators (This risk was inadvertently left off last month 15+)

PR6




Actionee 600 Risk of failure to replace Breas

SC20 sleep monitoring equipment.

PR6

601 Risk of injury from slip and from ceiling collapse

BL reported that ceiling is flaking, not collapsing.

PR6

602 Risk in use of Iridex SLX diode laser in ophthalmic procedures

PR4, PR9

603 Risk of misdiagnosis of Carbon Monoxide poisoning

PR6

604 Risk of lack of ultrasound scanner for Labour Ward

PR6

605 Risk of injury to staff and patients – theatre light in Theatre 8

PR6

607 Risk of unavailability of A&E ECG machine

PR6

608 Risk of failure of Cardiotocograph machine

PR6

It was AGREED that the high score purchasing risks that have been allocated to principal Risk 6 – Equipment and Facilities Arrangements, should be submitted to the Medical Devices Committee for information.

AEC

7. Any Other Business

7.1 Board Action Plan

JFC tabled a draft Board Action Plan for February 2008. After discussion, the Risk Management Committee: • NOTED – the Board Action Plan was a section of the Principal Risk

and Assurance Register, but would be a separate document in future. An updated Board Action Plan would be routinely presented to the Committee.

• NOTED – the Board Action Plan had been presented to the Executive Directors’ Group with a request that any gaps in controls and assurances are identified and remedial action put in place, so the organisation can demonstrate they are managing the Principal Risks.

• NOTED - the Board Action Plan would be presented to the Executive Directors’ Group on a monthly basis, following which the report would be presented to the Risk Management Group. The document will also be presented to the Audit and Assurance Committee and the Trust Board.

• REQUESTED –that those actions identified as “planned” be checked to ensure the actions were being undertaken.

• NOTED – the document was to provide assurance to the Audit and Assurance Committee and Trust Board and to ensure they are not distracted from the high level strategic risks.

• REQUESTED – that AD is entered as the Lead Director under Principal Risk 2 – Strategic and Business Planning – Ref. 2.7 and 2.8.

JFC

JFC

8. Date and Time of Next Meeting

Thursday, 17 April 2008 2.30 – 4.30 p.m. Chichester Board Room


RISK MANAGEMENT COMMITTEE

Thursday 17 April 2008 Chichester Board Room

PRESENT :

Andy Robinson (Chair) Director of Finance & Performance (AR) Tony Blake IT Services Manager (TB) Annette Crew Risk & Incident Manager (AEC) Juliet Cross Head of Corporate Affairs (JFC) Colin Dart Deputy Director of Finance (CD) Jo Gibbs Director of Operations (JG) Mike Lock Planning and Performance Manager (ML) Pauline Lockwood Modern Matron, South Molton (PL) Bob Lowe Deputy Estates Manager (BL) Carolyn Mills Director of Nursing (CM) Catherine Oliver Director of Human Resources (CO) Janet Phipps General Manager, Women’s and Children’s

Services (JP) Caroline Raby Senior Nurse, Clinical and Support Services

(CR)

IN ATTENDANCE: Margaret Gill Minute Secretary Julie Poyner Compliance Manager (attending for Clinical

Governance Manager) MINUTES


Apologies were received from:

Alison Diamond Associate Medical Director - Clinical Governance

(AD) Sam Jones Non-Executive Director (SJ) Nikki Kennelly Interim Director of Community Services (NK) Mandy Kilby Clinical Governance Manager (MK) Kate Maynard Director of Development (KM) Katharine Robinson A&E Consultant (KR) Martin Scrace Head of IM&T (MS) Bindy Sumner Staff Organisations Committee Chris Thomas Senior Nurse/Head of District Nursing (CT) Amelia Tucker-Jones Non-Executive Director (ATJ)

2. Minutes of last meeting The minutes of the meeting held on 20 March 2008 were ACCEPTED, with the following amendment: 3.4 Risk in the use of cot sides/bed rails Amend ‘Bed Release Policy’ to read ‘Bed Rails Policy’.

3. Matters Arising 3.1 3.1 - Risk ID 537 – Hip Replacements/Implants

AR reported that AD briefed the Executive Committee on the information provided by Christopher Mills on the Northern Devon Healthcare NHS Trust’s hip replacements/implants process/procedure.



Actionee Action closed.

3.2 3.3 - High Scoring Risks (15+) – December 2007 - Risk ID 543 – Risk

of failure of piped oxygen supply to NDDH site AEC reported that she had met with Paul Cooper on 24 March 2008. Action closed. BL reported that he had contact British Oxygen Company (BOC) regarding the siting of the acute hospital oxygen supply. BOC would be visiting the site to carry out a survey and would be making recommendations on where the oxygen could be sited in line with future site plans contained in the Estates Strategy. BL would report back to the meeting once more information was available.

3.3 3.4 – Risk ID 485 – Risk in the use of cot sides/bed rails CM reported that delivery of the new beds was scheduled for 10/11 and 17/18 May. Action continues.

3.4 3.5 – Torrington Incident JFC advised that the basic draft report had been circulated to the review team and she would chase this up. Action continues.

3.5 6.3 – Principal Risk and Assurance Register (PRAR)

Risk ID 574 – Endoscopy Scopes Risk ID 575 – Provision of Orthotics – Podiatry Service Risk ID 578 – Podiatry services staffing Actionees not at meeting – to be referred to the next meeting. AEC to check no urgent actions are outstanding. Actions continue.

3.6 4.4 Exceptions Report – March 2008 Risk ID 472 – Risk associated with rain water coming through the ceiling in PA 44 (Pathology Laboratory) BL reported that the Estates Department are working closely with Pathology and will attend immediately the next time an incident occurs to undertake investigation of the reported problem. Action closed.

3.7 4.4 Exceptions Report – March 2008 Risk ID 510 – Inadequate Ventilation in patient shower rooms. BL reported that this risk covered a larger area than first reported, and the whole of the ventilation system on that side of the hospital was being investigated. Facilities Department were working closely with Capener Ward on this. Action continues.

BL

CM

JFC

MKi NK NK

AEC

BL



Actionee

3.8 6.3 Principal Risk and Assurance Register (PRAR) – March 2008 AEC reported that work was ongoing to prepare the list of risks involving equipment for submission to the Medical Devices Committee for information. Action continues.

3.9 7.1 Board Action Plan JFC reported that the requested amendments had been made to the Board Action Plan. Action closed.

AEC

4. Corporate Risk Register 4.1 Corporate Risk Register Update Report – April 2008

AEC presented the update report dated April 2008, which summarised and updated information on New Risks, Accepted Risks and Exception reports dated March 2008. Included on the Corporate Risk Register Update Report was a table of totals outlining whether the risks were of Low, Medium or High scores for New Risks and Accepted Risks and a table in the Exceptions section of the Report detailing Risk Exception Reason totals.

4.2 New Risks – April 2008

AEC reported there were 17 new risks, three of which were scored at 15+. Following discussion, the Risk Management Committee: • NOTED – Risk ID 610 Risk of the breach of the Trust’s data

protection processes – the potential risk had been identified in September 2007 but had not been formally assessed for entry on on the Risk Register at that time. Necessary actions had been taken and the risk score had been reduced.

• NOTED – the New Risk Report for April 2008. 4.3 Accepted Risks – April 2008

AEC reported that 16 risks were recommended to be accepted for the month of April, where the manager of the risk had confirmed that all action plans had been completed and the risk had been rescored. Eleven of the risks recommended for acceptance had an initial score of 15+. Following discussion, the Risk Management Committee: • NOTED there had been an error on the report for March. Risk ID 574

Failure of Endoscopy Scopes is a duplicate risk of Risk ID 549 Risk of failure of Duodenoscopes – Endoscopy Suite. The accepted score for Risk ID 549 was shown as 15 but should have been shown as 4. AEC reported that the information had been amended on DATIX and the risks cross-referenced.



Actionee • APPROVED the risks presented in the Accepted Risks – April 2008

Report.

4.4 Exceptions Report – April 2008

AEC reported on the exception report as at April 2008 Following discussions the Risk Management Committee: • NOTED - that 65 exceptions were recorded for the month. • NOTED – that 48 risks had amendments to action plans, due dates,

etc. • NOTED - that no response had been received from 15 requests for an

update. • NOTED – Risk ID 379 – Risk from lack of capacity of IT

Information Staff may lead to priority information not being available in a timely manner – AEC to chase Martin Scrace for an update

• NOTED – Risk ID 503 – Risk of non compliance with Regulatory Reform Order (Fire Safety) 2005. Score 5x 4 = 20. The controls in place have been reviewed and amended. The percentage of managers who have completed fire risk assessments has been reassessed by the Fire and Security Officer as 40%. BL to investigate whether the Fire and Security Officer requires support to undertake the fire risk assessments. BL to enquire whether the whole of the Women’s and Children’s Directorate had undertaken their Fire Risk Assessment.

• NOTED – Risk ID 536 – Risk from use of unfamiliar equipment – Orthopaedic Loan Equipment – AEC to chase for update as it was considered the action plan does not reflect the latest agreed actions.

• NOTED – Risk ID 551 – Risk of demand for temporary staff exceeding availability – 17.5% of the vacant posts were unfilled.

• NOTED – Risk ID 552 – Risk to patient welfare from small admission room – Endoscopy – This risk requires re-assessing for transferring to form part of the Estates Strategy, as the Lead Manager would not be in a position to resolve this risk. AEC to contact Rowena Green.

• NOTED - Risk ID 593 – Risk from A&E Triage Room not fit for purpose – IT had now relocated the printers from this room.

• NOTED – the risks presented in the Exceptions Report – April 2008.

AEC/MS

BL

BL

AEC

AEC/RG

5. Principal Risk and Assurance Register 5.1 Corporate Risk Register Summary – April 2008

AEC reported on the Corporate Risk Register Summary for April 2008. Following discussions the Risk Management Committee: • NOTED – Risk ID 381 – Clinical & Support Services Project –

Radiology – Savings not met – should be rescored down and accepted.



Actionee • NOTED – Risk ID 455 – Theatre 8 theatre bed not suitable for

women weighing in excess of 133kg – the bed had been delivered and commissioned. JP will chase the Manager of the risk to update this risk.

• NOTED – Risk ID 615 – Risk of failure to provide a safe environment for patients, public and staff due to gap in Violence and Aggression policy – Two pilot studies are being undertaken on Staples Ward and South Molton Community Hospital into the procedures to be implemented when dealing with patients who have a medical reason for violent or aggressive incidents. The result of the pilot study would be reviewed by the Violence and Aggression Task and Finish Group and recommendations incorporated into the relevant policies.

• REQUESTED – Risk ID 627 – Risk of failure of Endoscopy scope printer – AEC to request the Manager of the risk to check the score of this risk.

• NOTED the Corporate Risk Register Summary for April 2008.

5.2 High Scoring Risks (15+) – April 2008

AEC presented the details of the High Scoring Risks 15+ as at April 2008.

5.3 Principal Risk and Assurance Register (PRAR) – March 2008

The RMC considered four new 15+ risks:

Risk ID

Title Comment Principal Risk

615 Risk of failure to provide a safe environment for patients, public and staff due to gap in Violence and Aggression policy.

PR5

616 Risk of failure of Electromyography machine

PR6

625 Risk to providing appropriate qualified staff on Glossop Ward.

PR3

627 Risk of failure of Endoscopy scope printer

PR6

JFC presented the Principal Risk and Assurance Register. Following discussion, the Risk Management Committee: • NOTED – the new reporting schedule will be presented in its entirety

to the Risk Management Committee, the Audit and Assurance Committee and the Trust Board twice a year.

• NOTED – Section 1 contained the current Trust Principal Risks (11 at the moment), but this could change depending on whether the Trust considers it is no longer a risk or new risks to the Trust are identified. This will be updated for the current year.

• NOTED – Section 2 contains detail of each Principal Risk. Information would be added to this on a monthly basis.

• NOTED the connection between the Gaps in Controls and Action

JG

JP

AEC



Actionee Plans.

5.4 Board Action Plan – April 2008

JFC reported on the Board Action Plan for April 2008. Following discussion, the Risk Management Committee: • NOTED that the Board Action Plan will be used more effectively in

future and would be presented to the Executive Directors’ Group, the Risk Management Committee, the Audit and Assurance Committee and Trust Board on a monthly basis.

• NOTED the Board Action Plan for April 2008.


6.1 Risk Management Policy

JFC reported that the Risk Management Policy was being updated and would be circulated to members next week. Following discussion, the Risk Management Committee: • NOTED the amended document was as a result of the NHS Litigation

Authority (NHSLA) Assessment, who had requested that the information contained in the Risk Management Strategy be divided into a separate Risk Management Policy.

• NOTED that any member of staff could complete an assessment form, but that the information submitted could be challenged.

• NOTED the NHSLA had questioned the absence of Local Risk Registers within the Trust. The Corporate Risk Register is held on the Datix database. There are no separate Local Risk Registers as all identifiable risks are being recorded on the Corporate Risk Register. Reports can be produced for Wards/Teams/Directorates from the Corporate Risk Register on request.

• NOTED that the Estates Department kept three Risk Registers, as follows:

o Risk adjusted backlog maintenance o Corporate Risk Register for Estates issues. o Estate’s Risk Register for 1-1 risks.

BL to liaise with AEC and JFC regarding Risk Registers kept by Estates Department.

• NOTED that it was intended to submit the policy for consideration to the Health and Safety Committee and Clinical Governance Committee.

• AGREED that as there was a tight time deadline, the Policy could be emailed to members for comments to be received back to JFC by 25 April 2008. Subject to any amendment, the Risk Management Committee approved the policy.

6.2 Endoscopy – Barrier Nursing – Single Pressurised Rooms

Discussion took place on the risk score, the assessment having been done through Barrier Nursing. AEC advised that the Infection Control Risk Register was to be presented to the next Infection Control meeting, when

BL/AEC/ JFC

JFC




Actionee this risk would be considered.

6.3 Power Supply to the Hospital

BL reported that the risk of interrupted electricity supplies to the hospital had not been finalised. He would report back to the next meeting.

BL


Thursday, 15 May 2008 2.30 – 4.30 p.m. Chichester Board Room


RISK MANAGEMENT COMMITTEE DRAFT

Thursday 15 May 2008 Chichester Board Room

PRESENT :

Annette Crew Risk & Incident Manager (AEC) Juliet Cross Head of Corporate Affairs (JFC) Colin Dart Deputy Director of Finance (CD) Alison Diamond (Chair) Associate Medical Director (AD) Mandy Kilby Clinical Governance Manager (MK) Bob Lowe Deputy Estates Manager (BL) Katharine Robinson A&E Consultant (KR) Bindy Sumner Staff Organisations Committee (BS) Amelia Tucker-Jones Non-Executive Director (ATJ)

IN ATTENDANCE: Sarah Ashton Datix Support Assistant Margaret Gill Minute Secretary Kate Ogilvie Assistant General Manager, Women’s and

Children’s and Sexual Health (KO) [attending for Janet Phipps]

MINUTES


Apologies were received from: Tony Blake IT Services Manager (TB) Jo Gibbs Director of Operations (JG) Sam Jones Non-Executive Director (SJ) Nikki Kennelly Interim Director of Community Services (NK) Mike Lock Planning and Performance Manager (ML) Pauline Lockwood Modern Matron, South Molton (PL) Kate Maynard Director of Development (KM) Andy Robinson Director of Finance & Performance (AR) Carolyn Mills Director of Nursing (CM) Catherine Oliver Director of Human Resources (CO) Janet Phipps General Manager, Women’s and Children’s

Services (JP) Caroline Raby Senior Nurse, Clinical and Support Services (CR) Martin Scrace Head of IM&T (MS) Chris Thomas Senior Nurse/Head of District Nursing (CT)

2. Minutes of last meeting The minutes of the meeting held on 17 April 2008 were ACCEPTED.

3. Matters Arising 3.1 3.2 - High Scoring Risks (15+) – December 2007 - Risk ID 543 – Risk

of failure of piped oxygen supply to NDDH site BL reported that the proposed visit of BOC to the site had been delayed due to the company going through a period of reorganisation. The site meeting was now arranged for 2 June, and it was hoped that an action plan would be developed following this meeting.

BL




3.2 3.3 – Risk ID 485 – Risk in the use of cot sides/bed rails JFC reported that the new beds had been received and the first tranche delivered to wards over the previous weekend, which was very successful. The second tranche was to be delivered over the coming weekend. AEC reported that the Use of Bed Rails Policy was being developed. The use of bed rails will be assessed on an individual patient basis and a Patient Risk Assessment is being developed to prevent slips, trips and falls. Action complete.

3.3 3.4 – Torrington Incident JFC advised that the report on the Torrington Incident was to be discussed at the ‘Learning from Staff and Patient Experience Group’. Action complete.

3.4 6.3 – Principal Risk and Assurance Register (PRAR)

AEC reported as follow: Risk ID 574 – Endoscopy Scopes These are fourth on the priority list for replacement, but no funds are currently available. AR will liaise with Mike Ambridge. Action continues. Risk ID 575 – Provision of Orthotics – Podiatry Service The Head of Podiatry Services is currently on extended sick leave and AEC had not initially been able to trace a responsible manager. AEC will liaise with Jackie White, deputy to the Head of Podiatry Services and Jill Smith, Interim Director of Health and Social Care. Action continues. Risk ID 578 – Podiatry services staffing The Head of Podiatry Services is currently on extended sick leave and AEC had not initially been able to trace a responsible manager. AEC will liaise with Jackie White, deputy to the Head of Podiatry Services and Jill Smith, Interim Director of Health and Social Care. Actions continue.

3.5 3.7 Exceptions Report – March 2008 Risk ID 510 – Inadequate Ventilation in patient shower rooms. BL reported that work was ongoing in an attempt to rectify this problem. Once all the asbestos and mechanical work had been undertaken in Brownlees Ward, the system would be re-balanced, which was hoped would rectify the problem. BL would report back on whether the ventilation in patient shower rooms had been improved once all necessary work had been completed.

AR/Mike Ambridge

AEC

AEC

BL




3.6 3.8 Principal Risk and Assurance Register (PRAR) – March 2008 AEC reported that the next meeting of the Medical Devices Committee was scheduled for 17 October 2008 and a report regarding 15+ risks involving equipment would be provided for the information of that Committee. Action closed.

3.7 4.4 Exceptions Report – April 2008 Risk ID 379 – Risk from lack of capacity of IT Information Staff may lead to priority information not being available in a timely manner AEC reported that all vacant posts had been filled and some work was ongoing with Human Resources regarding rebanding a position. The risk was to be reviewed in May, when it was hoped it would be recommended for acceptance. Action closed.

3.8 Risk ID 503 – Risk of non compliance with Regulatory Reform Order (Fire Safety) 2005. Score 5x 4 = 20. BL reported as follows: • That each departmental manager is responsible for producing their fire

risk assessment, which must be reviewed at least yearly or if there is any change in operation, physical modifications, room changes of use, etc.

• Martin Keightley (MK), Fire and Security Officer, carries out an annual Fire and Security audit on every department which includes an inspection of the departmental fire risk assessment.

• The 40% compliance is based on a projection by MK; last year’s outcome was a figure of only 30% of departments completing them. So far to date whilst MK has been carrying out his Fire and Security audits he has seen an increase in the department assessments. He believes this number will increase as the year progresses, but will keep the Committee informed via BL.

• With regard to the appointments issue for MK’s fire and security audits, the first letter is sent to the department manager. If this fails a second letter is sent to the line manager and department manager, and if no response, a third letter is sent to the Director, line manager and department manager.

• MK has reported that to date this year there has been an improvement, but again he will keep the Committee informed via BL.

• Women’s and Children’s Department annual fire and security audit is not due until later in the year.

Action closed.

3.9 Risk ID 552 – Risk to patient welfare from small admission room –

Endoscopy AEC reported that the Risk Manager had been amended to Rowena Green. Work will take place on reviewing the utilisation of space/matching



Actionee to patient pathways within the Endoscopy Service. Action closed.

3.10 5.1 - Risk ID 455 – Theatre 8 theatre bed not suitable for women weighing in excess of 133kg AEC reported that the Theatre 8 theatre bed had now been delivered and the risk was included in the Accepted Risks Report. Action closed.

3.11 5.1 - Risk ID 615 – Risk of failure to provide a safe environment for patients, public and staff due to gap in Violence and Aggression policy JFC reported that this risk had been highlighted by the Violence and Aggression Task Group and a pilot study had been undertaken, the results of which would be reported to the next meeting of the Violence and Aggression Task and Finish Group. Recommendations would then be rolled out across the organisation, and when agreed the Violence and Aggression Policy would be updated to include this. Action closed.

3.12 5.1 - Risk ID 627 – Risk of failure of Endoscopy scope printer

AEC reported that the quote for the equipment had been received and an order placed. Once delivered, the risk would be reviewed and the score reassessed. Action continues.

3.13 6.1 – Risk Management Policy JFC reported that she had still to meet with BL regarding the Risk Registers held by Estates Department. Action continues. JFC reported that the Risk Management Policy was scheduled to go to the May Clinical Services Executive Committee and June Board meeting. Action closed.

3.14 6.3 - Power Supply to the Hospital BL reported that liaison was ongoing with Western Power to alleviate problems experienced with the power supply to the hospital site. Some problems are caused by the site’s characteristics and how electricity is used on site. Recommendations to alleviate some of these was being submitted to the Director of Facilities for consideration. It was hoped that a protocol would be produced to ensure sensitive areas are covered and BL would report back to the Committee once a list of actions was completed. Action continues.

AEC

JFC/BL

BL

4. Corporate Risk Register



Actionee 4.1 Corporate Risk Register Update Report – May 2008

AEC presented the update report dated May 2008, which summarised and updated information on New Risks, Accepted Risks and Exception reports dated May 2008. Included on the Corporate Risk Register Update Report was a table of totals outlining whether the risks were of Low, Medium or High scores for New Risks and Accepted Risks and a table in the Exceptions section of the Report detailing Risk Exception Reason totals.

4.2 New Risks – May 2008

AEC reported there were 18 new risks, six of which were scored at 15+. Following discussion, the Risk Management Committee: • NOTED – Risk ID 631 – Risk to Patient Safety due to

administration of medication via incorrect route – The person who had assessed the risk had reported that all controls were in place and the risk was now recommended for acceptance.

• NOTED - Risk ID 634 – Risk that the Trust’s evidence of compliance with the Standards for Better Health is not sufficiently robust - The person who had assessed the risk had reported that all controls were in place and the risk was now recommended for acceptance.

• NOTED – Risk ID 635 – Risk that the Trust’s plans for financial recovery are not sufficiently robust - The person who had assessed the risk had reported that all controls were in place and the risk was now recommended for acceptance.

• NOTED – Risk ID 638 – Risk of delay in cleaning beds between occupants – Carolyn Mills had contacted the Ward Manager regarding this risk and AEC was awaiting feedback.

• NOTED – the New Risk Report for May 2008. 4.3 Accepted Risks – May 2008

AEC reported that ten risks were recommended to be accepted for the month of May, where the manager of the risk had confirmed that all action plans had been completed and the risk had been rescored. Five of the risks recommended for acceptance had an initial score of 15+. Following discussion, the Risk Management Committee: • NOTED – Risk ID 504 – Risk of fire – residences heating system –

80% of the residences have been provided with safer convector heaters, with the exception of Chichester House, where signs have been placed near bar heaters to warn of the risk. The Fire and Safety Adviser has reviewed the remaining risk and recommended that the residual risk remains at a score of 15+.

• APPROVED the risks presented in the Accepted Risks – May 2008 Report.

4.4 Exceptions Report – May 2008

AEC/LJ



Actionee AEC reported on the exception report as at May 2008 Following discussions the Risk Management Committee: • NOTED there were 47 exceptions recorded for the month. • NOTED – Risk ID 433 – Risk of failure of the only boiler serving

SSD Washer/Disinfectors/Autoclaves – This risk was reopened by the Sterile Services Manager following a breakdown of the old boiler, before the new boiler had been inspected for insurance purposes and therefore was unable to be used. The insurance inspection had now been arranged and it was anticipated that the risk would be accepted at the next Risk Management meeting.

• NOTED there were four risks where no response had been received to requests for update information for two consecutive months and letters had been sent from the Director of Finance and Performance as per the Exceptions Protocol. AEC had followed up the other risks where no response had been received for two consecutive months.

• NOTED – Risk ID 588 – Risk in use of A&E ventilators of different type to others in hospital – KR reported that they were still waiting for a response from EBME regarding this. BL will investigate.

• NOTED – Risk ID 593 – Risk from A&E Triage Room not fit for purpose – an action plan regarding recommended alterations to the Triage Room would be produced to the next meeting and a Business Case developed.

• NOTED – Risk ID 607 – Risk of unavailability of A&E ECG machine - KR reported that they were still waiting for a response from EBME regarding this. BL will investigate.

• NOTED the risks presented in the Exceptions Report – May 2008.

BL

KR

BL

5. Principal Risk Register 5.1 Corporate Risk Register Summary – May 2008

AEC reported on the Corporate Risk Register Summary for May 2008 and advised that a table on the 15+ accepted risks was now included at the end of the Corporate Risk Register Summary for information. Following discussions the Risk Management Committee: • NOTED - Risk ID 405 – Potential clinical risk of mismanagement

of patient care due to standard of documentation – Corporate Risk Register Summary to be amended to include whole of title.

• NOTED - Risk ID 435 – Risk of being unable to confirm the right patient received the right blood – there is a final action to be completed on this risk. It was hoped that the risk will be updated and accepted next month, but the score would not reduce as it is a legal requirement that the Trust is not currently complying with.

• NOTED – Risk ID 477 – Risk of harm from incorrect administration of medication/fluids from infusion devices – an audit is being undertaken on this risk, which is due for completion at the end of May.

• NOTED – Risk ID 507 – Potential risk of mismanagement of patient care due to inappropriate skill mix and workload of midwifery staff – no additional investment had been received from Devon Primary Care Trust for this service. A review of all services is



Actionee being undertaken, when the priorities will be identified and a Business Case compiled.

• NOTED – Risk ID 550 – Excessive temperatures – Pathology Laboratories - new equipment had been ordered, which should not generate so much heat as the present equipment.

• NOTED the Corporate Risk Register Summary for May 2008.

5.2 High Scoring Risks (15+) – May 2008

AEC presented the details of the High Scoring Risks 15+ as at May 2008.

5.3 Principal Risk and Assurance Register (PRAR) – May 2008

The RMC considered six new 15+ risks:

Risk ID

Title Comment Principal Risk

627 Risk of failure of Endoscopy scope printer

PR6

636 Risk to ongoing sustainability and improvement in the reduction of HCAIs

PR10

637 Risk to patient hygiene and privacy and dignity – bathrooms on KGV Ward

PR6

638 Risk of delay in cleaning beds between occupants

PR11

640 Risk of non-achievement of 08-09 service improvement, efficiencies and financial savings

PR1

642 Risk to customer care and Health and Safety – KGV Ward

PR6

JFC presented the Principal Risk Register. Following discussion, the Risk Management Committee: • NOTED the Principal Risk Register for May 2008.

5.4 Board Action Plan – May 2008 JFC reported on the Board Action Plan for May 2008. Following discussion, the Risk Management Committee: • NOTED that in line with recommendations made at a Board Briefing

amendments had been made to the Board Action Plan. • NOTED that the purpose of the Board Action Plan was to highlight the

Trust’s Principal Risks linked to the Strategic Objectives. New information would be in bold typeface and information marked in italic




Actionee typeface denoted reminders of forthcoming reviews / returns / assessments for ease of identification.

• NOTED New Principal Risks would be added as identified by the Risk Management Committee or the Executive Committee.

• NOTED that a Training and Study Leave Policy was being presented to the Clinical Services Executive Committee for approval in May and for ratification by the Trust Board in June 2008.

• NOTED that following discussion at the Executive Committee, a letter was to be sent to managers across the Trust requesting information on the partnership working involved in their area, to enable all requirements to be included in any Service Level Agreements.

• NOTED that an additional column would be added to the tables indicating a traffic light system on progress/level of risk.

• NOTED the Board Action Plan would be presented to the Executive Directors’ Group every month to be updated as required and would then be presented to the Risk Management Committee.

• NOTED the Action Plan would be presented to the Audit and Assurance Committee and Trust Board on a regular basis.

• NOTED an Integrated Business Plan was being developed and was due to be presented to the Trust Board in June 2008.

• NOTED the Board Action Plan for May 2008.


6.2 Health and Safety Policy

JFC reported that the Health and Safety Policy would be deferred for discussion to the next meeting. The finalised Policy would be sent to the members of the Health and Safety Committee requesting approval, and would then be sent on to the members of the Risk Management Committee and the Clinical Governance Committee with a request for any comments.

6.2 Review of Accepted Risks

JFC reported that the validation exercise on the Corporate Risk Register was being planned, where all accepted risks will be referred back to the relevant Risk Manager to ascertain the current status of the risk and confirm whether any further action had been taken in regard to the risk. Where a risk was re-opened, it would be brought back into the Datix system. The validation exercise will be undertaken on an annual basis. JFC reported that also, on a monthly basis, controls have been introduced to ensure that all information is updated in the control section of the risk database so there is a clear audit trail. Checks will be made on 15+ risks on a six-monthly basis.

JFC / S Parker


Thursday, 19 June 2008 2.30 – 4.30 p.m. Chichester Board Room

report to trust board - northern devon healthcare nhs trust · 6/3/2008 · for information. •...

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