Risk Assessment Policy - the Royal Cornwall Hospitals Trust website...
Risk Assessment Policy - the Royal Cornwall Hospitals Trust website...
Risk Assessment Policy - the Royal Cornwall Hospitals Trust website...
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Document Reference Code RM/006/09This document is only valid on <strong>the</strong> day of printing:Title:Developed by:Document Definition:Ratified by:<strong>Risk</strong> <strong>Assessment</strong> <strong>Policy</strong>Pauline Claridge, <strong>Risk</strong> ManagerReviewed by Debra Spear – Health, Safety and Improvement Manager<strong>Policy</strong>Tim Archer, Director of Delivery and Performanceon: 16 th March 2009Date to be reviewed:Review arrangements:Document location:See version control tableAuthorB3 Section of <strong>the</strong> Intranet document library, <strong>Trust</strong> <strong>website</strong>1 SummaryThe <strong>Trust</strong> is committed to complying with <strong>the</strong> spirit and intent of <strong>the</strong> Health and Safety atWork Act 1974, subsequent legislation and <strong>the</strong> requirements laid down by <strong>the</strong> NHSLitigation Authority and <strong>the</strong> National Patient Safety Agency to identify, reduce, control andmonitor ALL risks within <strong>the</strong> Organisation.2 Who this document is relevant to:The document is relevant to all Managers, Health and Safety Leads and all staff workingfor <strong>Cornwall</strong> Partnership NHS Foundation <strong>Trust</strong>.3 Related <strong>Trust</strong> PoliciesLone Working <strong>Policy</strong><strong>Risk</strong> Management StrategyHealth and Safety <strong>Policy</strong> StatementCOSHH <strong>Policy</strong>Medical Devices <strong>Policy</strong> 2008Manual Handling <strong>Policy</strong>Management of Violence and AggressionYoung Persons <strong>Policy</strong>Managers guide on Maternity: Safe Employment and <strong>Risk</strong> <strong>Assessment</strong> – Child CareCoordination TeamManagement and Reduction of <strong>Risk</strong> of Falls in Hospital Care4 Related legislation and national guidanceDepartment of Health (2000) An organisation with a memory, report of an expert group onlearning from adverse events in <strong>the</strong> NHS chaired by <strong>the</strong> Chief Medical Officer, StationaryOffice, London. ISBN 011 322441 9.Department of Health (2001) Building a safer NHS for patients –www.doh.gov.uk/buildsafenhsDepartment of Health (2004) <strong>Risk</strong> Management Organisational Controls Standard,Standards for Better HealthPage 1 of 70
Document Reference Code RM/006/09NHSLA (2008) <strong>Risk</strong> Management Standard 5, <strong>Risk</strong> Management Standard 1, Governance,Criterion 5, <strong>Risk</strong> Management Standard 3, Safe Environment Criterion 5, Slips, Trips andFallsHealth and Safety at Work Act 1974 – www.healthandsafety.co.uk/haswa.htmManagement of Health and Safety at Work Regulations 1999 –www.legislation.hmso.gov.uk/si/si1999/19993242Control of Substances Hazardous to Health (COSHH) Regulations 2002 –www.hse.gov.uk/lau/lacsNew and Expectant Mo<strong>the</strong>rs at Work: A guide for employers HSG122Young People at Work: A guide for employers HSG165<strong>Risk</strong> Management Working Group (2004): Making it Work – www.hcsu.org.uk5 Training RequirementsIncluded in <strong>the</strong> training needs analysis6 Equality Impact <strong>Assessment</strong>The Equality Impact <strong>Assessment</strong> Form was completed on 21 st January 20097 This document replaces:<strong>Risk</strong> <strong>Assessment</strong> <strong>Policy</strong> RM/006/048 Process for monitoring compliance and effectivenessThe completion of suitable and sufficient risk assessments will be <strong>the</strong> responsibility of eachTeam Leader/Manager, Community Services Managers and Modern Matrons.Monitoring of compliance within services will be <strong>the</strong> responsibility of <strong>the</strong> Associate NetworkDirectors through each Network’s Health and Safety and <strong>Risk</strong> Management Committees.An annual audit will be agreed, implemented and reviewed by <strong>the</strong> <strong>Trust</strong>’s <strong>Risk</strong>Management Committee. Monitoring compliance within o<strong>the</strong>r areas will be <strong>the</strong>responsibility of <strong>the</strong> <strong>Risk</strong> Management Strategy Group.Version ControlVersion Date Reviewed Changes By WhomSeptember 2013 Expiry date extended to 31 December 2013 as agreed S. Linterby Director of Quality and GovernanceNovember 2013 Expiry date extended to 28 February 2014 as agreedby Director of Quality and GovernanceS. LinterThis document can be accessed and printed via <strong>the</strong>Intranet Document Library and <strong>the</strong> <strong>Trust</strong> WebsitePage 2 of 70
ContentsDocument Reference Code RM/006/091. Introduction ....................................................................................................................... 52. Background ....................................................................................................................... 53 Benefits of <strong>Risk</strong> <strong>Assessment</strong> ............................................................................................ 64 Definitions ......................................................................................................................... 65 General <strong>Risk</strong> <strong>Assessment</strong> ................................................................................................. 76 <strong>Risk</strong> <strong>Assessment</strong> Guide .................................................................................................... 87 Getting Started ................................................................................................................. 98 Specialist <strong>Risk</strong> <strong>Assessment</strong> ............................................................................................ 139 Summary ......................................................................................................................... 17Appendix 1 – <strong>Risk</strong> <strong>Assessment</strong> Record .................................................................................. 18Appendix 2 – <strong>Risk</strong> Scoring Matrix ........................................................................................... 20Appendix 3 – <strong>Risk</strong> Register .................................................................................................... 23Appendix 4 – Steps in doing a <strong>Risk</strong> <strong>Assessment</strong> Flowchart ................................................... 24Appendix 5 – <strong>Risk</strong> Register Process....................................................................................... 25Appendix 6 – Examples/Hazards and <strong>Risk</strong>s, Associated <strong>Risk</strong> ............................................... 27Appendix 7 – New, Expectant and Breastfeeding Mo<strong>the</strong>rs <strong>Risk</strong> <strong>Assessment</strong> Process .......... 28Appendix 7a – <strong>Risk</strong> <strong>Assessment</strong> Checklist for ‘New and Expectant Mo<strong>the</strong>rs’ ........................ 30Appendix 8 – Young Persons <strong>Risk</strong> <strong>Assessment</strong> ..................................................................... 38Appendix 8a – Managers/Student Combined Plan Of Work Record Form And Checklist ForYoung Persons ....................................................................................................................... 39Appendix 8b – Example guidelines for <strong>Risk</strong> <strong>Assessment</strong>s for Managers of Young Persons . 43Appendix 8c – Example guidelines for <strong>Risk</strong> <strong>Assessment</strong>s for Managers of Catering Staff,Young Persons ....................................................................................................................... 45Appendix 8d – Young Persons combined <strong>Risk</strong> <strong>Assessment</strong> and Action Plan form ................ 47Appendix 9 – Display Screen Equipment Initial Checklist ....................................................... 48Appendix 10 – Control of Substances Hazardous to Health Regulations 2004 (COSHH)Inventory and Summary List of COSHH <strong>Assessment</strong>s ........................................................... 52Appendix 11 – Manual Handling Practical <strong>Assessment</strong> Form ................................................ 53Appendix 11a – Manual Handling Practical <strong>Assessment</strong> Form: Inanimate Load & PhysicalIntervention ............................................................................................................................. 54Appendix 11b – Manual Handling Guidance for Completing a Generic / Individual <strong>Risk</strong><strong>Assessment</strong> ............................................................................................................................ 55Appendix 11c – Client/Patient Manual Handling <strong>Assessment</strong> Form ....................................... 56Appendix 11d – Manual Handling ........................................................................................... 60Appendix 12 – Lone Workers pre <strong>Risk</strong> <strong>Assessment</strong> Checklist: Working alone in buildings ... 61Page 3 of 70
Document Reference Code RM/006/09Appendix 12a – Lone Workers Checklist: Domiciliary visits .................................................. 62Appendix 12b – T.M.A.V. Training Needs <strong>Assessment</strong> .......................................................... 63Appendix 13 – Initial Falls <strong>Assessment</strong> .................................................................................. 64Appendix 14 – Multi factorial Falls <strong>Risk</strong> <strong>Assessment</strong> .............................................................. 65Appendix 15 – Protocol for <strong>the</strong> use of <strong>the</strong> Multi factorial Falls <strong>Risk</strong> <strong>Assessment</strong> Tool ........... 68Appendix 16 – Minimising <strong>the</strong> <strong>Risk</strong> of Falls – Environmental <strong>Assessment</strong> ............................. 70Word versions of <strong>the</strong> following Appendices can be found on <strong>the</strong> document library usingkeyword ASSESSMENTAppendix 1 – <strong>Risk</strong> <strong>Assessment</strong> RecordAppendix 3 – <strong>Risk</strong> RegisterAppendix 7a – <strong>Risk</strong> <strong>Assessment</strong> Checklist for ‘New and Expectant Mo<strong>the</strong>rs’Appendix 8 – Young Persons <strong>Risk</strong> <strong>Assessment</strong>Appendix 8a – Managers/Student Combined Plan Of Work Record Form And Checklist For YoungPersonsAppendix 8d – Young Persons combined <strong>Risk</strong> <strong>Assessment</strong> and Action Plan formAppendix 9 – Display Screen Equipment Initial ChecklistAppendix 10 – Control of Substances Hazardous to Health Regulations 2004 (COSHH) Inventoryand Summary List of COSHH <strong>Assessment</strong>sAppendix 11 – Manual Handling Practical <strong>Assessment</strong> FormAppendix 11a – Manual Handling Practical <strong>Assessment</strong> Form: Inanimate Load & PhysicalInterventionAppendix 11b – Manual Handling Guidance for Completing a Generic / Individual <strong>Risk</strong><strong>Assessment</strong>Appendix 11c – Client/Patient Manual Handling <strong>Assessment</strong> FormAppendix 11d – Manual HandlingAppendix 12 – Lone Workers pre <strong>Risk</strong> <strong>Assessment</strong> Checklist: Working alone in buildingsAppendix 12a – Lone Workers Checklist: Domiciliary visitsAppendix 13 – Initial Falls <strong>Assessment</strong>Appendix 14 – Multi factorial Falls <strong>Risk</strong> <strong>Assessment</strong>Appendix 16 – Minimising <strong>the</strong> <strong>Risk</strong> of Falls – Environmental <strong>Assessment</strong>Page 4 of 70
1. IntroductionDocument Reference Code RM/006/09<strong>Cornwall</strong> Partnership NHS Foundation <strong>Trust</strong> accepts that <strong>the</strong> nature of its core business as amental health and learning disabilities <strong>Trust</strong> and some of its work activities may, unless properlycontrolled, create risks to patients, staff and o<strong>the</strong>rs and will, in accordance to legislation, take allreasonably practicable measures to reduce <strong>the</strong>se risks to an acceptable level. As directed withinlegislation and national guidance, all aspects of risk within <strong>the</strong> organisations, in accordance with<strong>the</strong> <strong>Trust</strong>’s core objectives will be assessed to determine what fur<strong>the</strong>r actions are required toreduce risks to people’s safety and to meet any statutory requirements.Corporate accountability for clinical performance and Health & Safety lies at <strong>Trust</strong> Board level, with<strong>the</strong> Chief Executive who takes overall responsibility. Responsibility is fur<strong>the</strong>r devolved to <strong>the</strong>Director of Nursing, Midwifery and Allied Health Professional’s (AHP’s), through its Directorates,Director of Delivery and Performance, Executive Nurse and Networks East and West.On a day-to-day basis <strong>Cornwall</strong> Partnership NHS Foundation <strong>Trust</strong> Managers are deemedresponsible for ensuring that risk assessments are carried out, and that appropriate and effectivemeasures to control risks are developed, implemented and monitored. This document is intendedas guidance in meeting this responsibility.In addition to <strong>the</strong> above, it is <strong>the</strong> responsibility of each and every individual working at all levelsacross <strong>the</strong> <strong>Trust</strong>, irrespective of grade/seniority, to take care of <strong>the</strong>mselves and o<strong>the</strong>rs. To thisend, individuals must notify <strong>the</strong>ir head of department/line manager of any hazard/risk that appearsto be inadequately controlled.2. Background<strong>Risk</strong> <strong>Assessment</strong> is a fundamental risk management tool, which forms part of <strong>the</strong> pro-activemanagement and decision making process in all areas of <strong>the</strong> Organisation.The focus for Clinical <strong>Risk</strong> Management within <strong>the</strong> <strong>Trust</strong> is <strong>the</strong> adoption of <strong>the</strong> national clinical riskmanagement standards through <strong>the</strong> NHS Litigation Authority <strong>Risk</strong> Management Standards,Clinical Negligence Scheme for <strong>Trust</strong>s (CNST).The CNST standards are about best practice in managing clinical risk, improving <strong>the</strong> quality ofcare we deliver and reducing harm to patients. Evidence is required that robust systems andprocesses are in place and operational across <strong>the</strong> <strong>Trust</strong>. Integral within this is <strong>the</strong> requirement toundertake a <strong>Trust</strong> wide clinical risk assessment.Section 2 (1) and 3 (1) of <strong>the</strong> Health and Safety at Work Act 1974 places a general duty on everyemployer to conduct <strong>the</strong>ir undertaking in such a way as to ensure, so far as is “reasonablypracticable”, that both employees and persons not in <strong>the</strong>ir employment who may be affected<strong>the</strong>reby are not exposed to risk to <strong>the</strong>ir health or safety. Under <strong>the</strong> Management of Health andSafety at Work Regulations 1999 (MHSWR), <strong>the</strong>re is an implicit requirement on every employer tomake a suitable and sufficient assessment of:• <strong>the</strong> risks to <strong>the</strong> health and safety of its employees to which <strong>the</strong>y are exposed whilst<strong>the</strong>y are at work; and• <strong>the</strong> risks to <strong>the</strong> health and safety of persons not in his employment arising out of, or inconnection with <strong>the</strong> conduct by him of his undertaking.Fur<strong>the</strong>rmore, <strong>the</strong> Health Services Advisory Committee (HSAC) have laid down a frameworkrequiring that <strong>the</strong> organisation can demonstrate that it has sound internal control systems in placefor identifying risks relating to <strong>the</strong> achievement of <strong>the</strong> <strong>Trust</strong>s aims and objectives, evaluating <strong>the</strong>Page 5 of 70
Document Reference Code RM/006/09nature and extent of those risks and managing <strong>the</strong>m effectively, efficiently and economically. Thecriteria applies equally to clinical and non- clinical risk issues and is based on an over-arching <strong>Risk</strong>Management standard which provides strict guidance on risk assessment.3 Benefits of <strong>Risk</strong> <strong>Assessment</strong>The realisation of risk in <strong>the</strong> form of incidents, accidents or ill health can present substantiallosses, both in human and financial terms. A progressive reduction of risk will produce benefitsnot only in <strong>the</strong> delivery of clinical care, but also <strong>the</strong> management of health and safety and <strong>the</strong>control of unnecessary losses.• Identifies <strong>the</strong> potential areas within Departments / Networks• Provides a co-ordinated and systematic approach to analysis and managing problemareas• Improves quality and standards of care for patients• Protects patients, staff and <strong>the</strong> <strong>Trust</strong>• Meets <strong>the</strong> requirements within <strong>the</strong> <strong>Trust</strong>’s governance framework• Feeds those risks which can not be managed locally upwards to higher levels ofmanagement and into business plans• Ensures a proactive ra<strong>the</strong>r <strong>the</strong>n reactive approachBy meeting <strong>the</strong> criminal law objective, o<strong>the</strong>r corporate risk benefits can be achieved including:• Reduction in exposure of <strong>the</strong> company and key personnel to criminal liability• Reduction in <strong>the</strong> risk of Directors’ disqualification from office• Reduction in exposure of company and senior managers to civil liability for death or injury• Reduction in financial risks and improved control over uninsured losses (e.g., lost time,repair costs, replacement costs of injured staff and/or damaged equipment, insuranceclaim excesses)4 Definitions<strong>Risk</strong> is <strong>the</strong> potential for an unwanted outcome, and <strong>Risk</strong> Management is concerned with <strong>the</strong>identification, analysis and control of any circumstances or practices which put patients, staff,visitors, contractors or <strong>the</strong> organisation at risk of harm or loss.A Hazard is something that has <strong>the</strong> potential to cause harm. For example this could be asubstance, piece of equipment or a work procedure.<strong>Risk</strong> is <strong>the</strong> probability or chance that harm from a particular hazard will occur. The extent of <strong>the</strong>risk includes <strong>the</strong> number of people affected, <strong>the</strong> consequences for <strong>the</strong>m and <strong>the</strong> impact across <strong>the</strong>organisation – <strong>the</strong> risk represents <strong>the</strong> consequences (severity) of harm and <strong>the</strong> likelihood of itoccurring.Harm includes death, bodily injury, ill health and damage to property, plant, equipment or <strong>the</strong>environment.<strong>Risk</strong> <strong>Assessment</strong> is defined as “Identifying <strong>the</strong> hazards present in any undertaking (whe<strong>the</strong>rarising from work activities or from o<strong>the</strong>r factors, e.g. layout of <strong>the</strong> premises) and <strong>the</strong>n evaluating<strong>the</strong> extent of <strong>the</strong> risks involved, taking into account whatever precautions are already being taken”(MHSWR, 1999).Page 6 of 70
Examples:Document Reference Code RM/006/09Hazard<strong>Risk</strong><strong>Risk</strong>HazardHandling clinical wastePossible infection from contaminationLigature PointHarm/self harm may be realised using accessible ligature point5 General <strong>Risk</strong> <strong>Assessment</strong>In everyday terms, a risk assessment is simply a careful examination of hazards that couldreasonably be expected to cause harm to patients, staff members, visitors and an evaluation of <strong>the</strong>way in which such hazards might cause harm or loss.<strong>Risk</strong> assessment applies to all activities, situations and substances. For assessment to complywith all legal requirements it is necessary to:• Identify <strong>the</strong> HazardsLook for all <strong>the</strong> hazards associated with <strong>the</strong> operation of <strong>the</strong> area under yourresponsibility and of <strong>the</strong> activities performed within it (see Appendix 6 for guidance).• Decide who might be harmed and howIdentify any groups or individuals – patients, employees or o<strong>the</strong>r persons who might beat risk, including pregnant workers, young persons or those with disabilities.• Evaluate <strong>the</strong> <strong>Risk</strong>sDecide whe<strong>the</strong>r <strong>the</strong> hazard can be eliminated altoge<strong>the</strong>r. If it cannot, determine how tocontrol <strong>the</strong> risk.Consider existing control measures, decide whe<strong>the</strong>r <strong>the</strong> procedure/activity/process should be:• Stopped• Treated i.e., instruction, training, information provision and supervision• Accepted or• TransferredJudge <strong>the</strong> likelihood or probability of an accident or incident occurring with consideration to <strong>the</strong>control measures all ready in place. It may be that <strong>the</strong>y are inadequate and require fur<strong>the</strong>r controlmeasures to manage <strong>the</strong> risk.The tool for evaluating and ranking is known as <strong>the</strong> <strong>Risk</strong> Scoring Matrix, designed in line withnational guidance and can be seen at Appendix 2.The <strong>Risk</strong> Scoring Matrix assists in quantifying <strong>the</strong> risk by multiplying <strong>the</strong> anticipated consequenceof <strong>the</strong> risk identified by <strong>the</strong> likely probability of <strong>the</strong> risk being realised:• Consequence x Likelihood = <strong>Risk</strong> RatingRecord FindingsUsing <strong>the</strong> <strong>Risk</strong> <strong>Assessment</strong> Record (appendix 1) record your findings of <strong>the</strong> hazard that has beenassessed. The <strong>Risk</strong> <strong>Assessment</strong> Record will be forwarded for escalation/acceptance at <strong>the</strong>appropriate level as identified on page 2 of <strong>the</strong> <strong>Risk</strong> Scoring Matrix.Page 7 of 70
Document Reference Code RM/006/09Safe KeepingThe risk assessment and supporting information should be kept within <strong>the</strong> area/service assessedensuring that it is available for staff and o<strong>the</strong>rs to familiarise <strong>the</strong>mselves with its content.<strong>Risk</strong> assessments that require fur<strong>the</strong>r resources to control/manage <strong>the</strong> identified risk will beescalated to form part of <strong>the</strong> Directorate/Network/Corporate <strong>Risk</strong> Register via <strong>the</strong> appropriatenetwork governance arrangements and reviewed by <strong>the</strong> <strong>Risk</strong> Management Strategy group bimonthly(see <strong>Risk</strong> Register process, appendix 5).ReviewIt is a legal requirement to maintain Health and Safety <strong>Risk</strong> <strong>Assessment</strong>s, collectively <strong>the</strong>y shouldbe seen as a ‘living’ document that is revised periodically or at any such time that <strong>the</strong>re aresignificant changes to a process, activity or <strong>the</strong> environment.6 <strong>Risk</strong> <strong>Assessment</strong> GuideConducting a <strong>Risk</strong> <strong>Assessment</strong>The tools within this policy are designed to support you and your colleagues to be proactive in:• Identifying <strong>the</strong> clinical and non clinical risks within your speciality, department or ward• Determining <strong>the</strong> level of risk that exists• Assessing <strong>the</strong>m for severity• Prioritising those risks requiring urgent attention• Examining <strong>the</strong> effectiveness of your current practice to manage those risks• Identifying what fur<strong>the</strong>r measures need to be taken to ei<strong>the</strong>r reduce or eliminate <strong>the</strong>risks• Ensuring appropriate actions are taken to <strong>the</strong>ir effectiveness monitoredThe basics of <strong>Risk</strong> <strong>Assessment</strong> lies in <strong>the</strong> answers to two fundamental questionsWhat could go wrong? i.e.,• What harm could be caused?• To whom could it be caused?• What hazards exist?• What precautions have already been taken?• What are <strong>the</strong> chances of it happening? (residual risk dependant on a – d)What fur<strong>the</strong>r precautions are needed to prevent it happening?• Stop• Treat• Transfer• AcceptPage 8 of 70
Document Reference Code RM/006/097 Getting StartedSee flow chart simplifying <strong>the</strong> steps of risk assessment – appendix 4Identify <strong>the</strong> HazardsThe first step in an assessment is identification of hazards/risks. <strong>Risk</strong> identification requires asystematic process to discover actual and potential areas of risk within yourWard/Department/Area of responsibility.Step 1 – establish your teamA risk assessment should not be conducted in isolation. It requires <strong>the</strong> input of those with localand wider knowledge, clinical expertise, and a ‘competent’ personThe relevant people are those able to assess <strong>the</strong> risks, those who are faced with <strong>the</strong> risks andthose who need to commit time, money, effort or o<strong>the</strong>r resources to implement <strong>the</strong> controlmeasures decided upon. This allows all staff of all grades and those with responsibility for tasks ineach part of a process to be involvedEveryone should be encouraged to participate and contribute to <strong>the</strong> process, <strong>the</strong> strength in thisprocess is that each individual will identify issues which are not immediately obvious to o<strong>the</strong>rs. Tothis end where risks cross organisational/directorate boundaries, representatives from those areasshould be included in <strong>the</strong> assessment process.Decide who might be harmed and howDivide <strong>the</strong> process into logical steps, this can be achieved by:• Considering <strong>the</strong> locations of work: inpatient/outpatient areas, team bases, public areasetc• Consider <strong>the</strong> people involved: service users/patients, members of staff, visitors, visitingmaintenance engineers/contractors etc• Consider <strong>the</strong> equipment used: instruments, diagnostic equipment, display screens,lifting equipment, heavy machinery• Consider procedures and systems of work – are <strong>the</strong>y safe?• Consider those known risks that could lead to death, disability or severe distressIgnore trivial scenarios and concentrate on inadequately controlled hazards with <strong>the</strong>potential to cause serious harm, affect several people or have a higher likelihood ofoccurrence or repetitionThe way in which this is achieved is non prescriptive. Personal experience of staff is an essentialsource of information to commence <strong>the</strong> process, however, information that has been ga<strong>the</strong>redwithin and externally to <strong>the</strong> <strong>Trust</strong> may also inform <strong>the</strong> identification process• Incidents, Accidents and Near Misses• Audit data – internal and NAO• Claims data – complaints• Patient feedback – complaints data• Clinical indicators• External reports – i.e., Healthcare Commission, Confidential Enquiries, HomicideReportsPage 9 of 70
Document Reference Code RM/006/09• Health and Safety Executive (HSE) Audit report• Feedback from <strong>the</strong> National Patient Safety Agency/Safety Alerts/MHRA alerts• Clinical Negligence Scheme for <strong>Trust</strong>’s (CNST) <strong>Risk</strong> Management Standards• Action plans for Standards for Better HealthSpecialised <strong>Risk</strong> <strong>Assessment</strong>Please note, this list is not exhaustiveWhen identifying ‘who’ may be harmed, it will be necessary to complete specific risk assessmentson vulnerable people in compliance with <strong>the</strong> Management of Health and Safety at WorkRegulations 1999 (MHSWR) (see section 8).Analysis and PrioritisationHaving identified a number of risks, obviously it will be necessary to prioritise which risks shouldbe dealt with first. This should be dictated by how effective any resulting control measures maybe.Grade each risk using <strong>the</strong> 5 x 5 Scoring matrix (appendix 2) to determine <strong>the</strong> potentialconsequences and <strong>the</strong> likelihood of <strong>the</strong> risk occurring.i.e., Consequence x Likelihood = <strong>Risk</strong>Reach conclusion within <strong>the</strong> assessment team s to whe<strong>the</strong>r <strong>the</strong> risks that have been identified arepredominantly clinical, health and safety, organisational or financial and how <strong>the</strong>y fit with <strong>the</strong>Corporate objectives.Control MeasuresHaving identified <strong>the</strong> hazard and <strong>the</strong> risk that it carries, it is necessary to identify• Which control measures are currently in place and whe<strong>the</strong>r <strong>the</strong>y are effective• Whe<strong>the</strong>r <strong>the</strong>re is something simple that could be done straight away to reduce <strong>the</strong>identified risk or• What control measures need to be put in place to fur<strong>the</strong>r reduce <strong>the</strong> risk or eliminate italtoge<strong>the</strong>rFur<strong>the</strong>r questions to be asked are• Can <strong>the</strong> risk be completely eliminated?• Can it be avoided?• Can it be made less likely?• What are <strong>the</strong> cost implications of introducing or not introducing fur<strong>the</strong>r controls?The relationship between <strong>the</strong> cost of controlling <strong>the</strong> risk and <strong>the</strong> benefits to be gained mustbe considered. Consideration should always be given to implementing measures that are‘reasonably practicable’Page 10 of 70
Document Reference Code RM/006/09Not all risk reducing measure that lots of resources!• Developing a robust policy or guideline• Organising training on using a piece of equipment• Raising awareness• Tightening up processes of a task• Developing a competency based assessment for a particular techniqueYour <strong>Risk</strong> <strong>Assessment</strong> should <strong>the</strong>n be forwarded to <strong>the</strong> Network General Manager to approve andrecord any actions required to be taken to fur<strong>the</strong>r ‘control’, reduce or eliminate <strong>the</strong> identified risk.<strong>Risk</strong> RankingUse <strong>the</strong> 5 x 5 <strong>Risk</strong> Scoring Matrix to reassess <strong>the</strong> risk rating with <strong>the</strong> recommended controlmeasures taken into consideration.<strong>Risk</strong>s that cannot be significantly reduced will need to be entered on <strong>the</strong> <strong>Risk</strong> Register andescalated by <strong>the</strong> Network/Service Managers and Modern Matrons through <strong>the</strong> Networks and up to<strong>the</strong> <strong>Trust</strong> Board if appropriate.Managers and Supervisors are required to ensure <strong>the</strong> most effective management of Health andSafety. To help <strong>the</strong>m to do this <strong>the</strong>y should ensure in <strong>the</strong> first instance and where necessary, thatany risks that required significant financial resources to ensure adequate control (i.e.,replacement/upgrading of environment) are placed on <strong>the</strong> <strong>Risk</strong> Register AND built into <strong>the</strong>business planning cycle.<strong>Risk</strong> RegisterThe <strong>Risk</strong> Register (appendix 3) is a <strong>Trust</strong> wide document, which is in place to facilitate monitoring,and <strong>the</strong> assurance that risks are being managed. It also assists in <strong>the</strong> assurance thatimprovements of <strong>the</strong> standard of care provided to patients and promotion of a healthy and safeenvironment for staff and visitors are embedded in <strong>the</strong> culture of <strong>the</strong> organisation.The Corporate <strong>Risk</strong> Register is reported to <strong>the</strong> <strong>Trust</strong> Board on a quarterly basis and containssignificant risk faced by <strong>the</strong> organisation.<strong>Risk</strong>s entered onto <strong>the</strong> Directorate <strong>Risk</strong> Registers are reviewed bi-monthly by <strong>the</strong> <strong>Risk</strong>Management Strategy Group.Local <strong>Risk</strong> Registers are owned and managed at local level and monitored within local governancearrangements.Amendments and updates can be reported using <strong>the</strong> <strong>Risk</strong> Register amendment form (appendix 3).Guidance on informing <strong>the</strong> <strong>Risk</strong> Register can be seen at appendixDocumentation<strong>Risk</strong> <strong>Assessment</strong>s and supporting information must be kept safe and available for submission ofevidence as and when required by inspectorate bodies. They are valuable evidence that <strong>the</strong>re hasbeen a systematic process acknowledging risk and <strong>the</strong> appropriate ways to manage that risk.Page 11 of 70
Document Reference Code RM/006/09<strong>Risk</strong> TreatmentResponsibility should be taken to ‘treat’ risk at <strong>the</strong> appropriate level, where fur<strong>the</strong>r resources,advice or collaboration is required, <strong>the</strong>se should be escalated as described previously. Detailedguidance for action and reporting requirements can be found on page 2 of <strong>the</strong> 5 x 5 <strong>Risk</strong> ScoringMatrix.Score <strong>Risk</strong> Action Reporting Requirements1 – 3 Low Managed through normalcontrol measuresManage at ward / department level4 – 6 Moderate Review control measures Managed by head of Department orequivalent and monitored at Directoratelevel8 – 12 High Treatment plans to bedeveloped, implemented andmonitored15 – 25 ExtremeImmediate action requiredTreatment plans to bedeveloped, implemented andmonitoredManaged within <strong>the</strong> Directorate, enteredonto Directorate <strong>Risk</strong> Register andreported to <strong>the</strong> appropriate <strong>Trust</strong> Boardsub committee for entry to Corporate<strong>Risk</strong> RegisterReport to <strong>Trust</strong> Board, enter ontoCorporate <strong>Risk</strong> RegisterMonitoringProgress against each action plan will be monitored at Directorate level and progress reports willbe submitted through <strong>the</strong> Network Governance Process within <strong>the</strong> <strong>Trust</strong> and escalated to <strong>Trust</strong>Board as required through <strong>the</strong> <strong>Risk</strong> Management Strategy Group.Effectiveness of measures put in place will be audited through local Network Governancearrangements.<strong>Risk</strong> <strong>Assessment</strong>s will be reviewed on an annual basis or any such time that <strong>the</strong>re are significantchanges to a process, activity or <strong>the</strong> environment.Communicating <strong>Risk</strong>It is a legal requirement that where risks have been identified that staff are informed of <strong>the</strong> risks.Employees have a duty under <strong>the</strong> Health and Safety at Work Act (1974) to comply with any safetypolicies or procedures put in place to ensure that <strong>the</strong>ir actions do not harm <strong>the</strong> health and safety ofo<strong>the</strong>rs and fur<strong>the</strong>rmore to protect <strong>the</strong>ir own health and safety.Network/Service Managers and Modern Matrons should make this information available within<strong>the</strong>ir Directorate.Page 12 of 70
8 Specialist <strong>Risk</strong> <strong>Assessment</strong>Document Reference Code RM/006/09Whilst <strong>the</strong> majority of <strong>Risk</strong> <strong>Assessment</strong>s may be undertaken using a General <strong>Risk</strong> <strong>Assessment</strong>record (appendix 1), <strong>the</strong>re are occasions/circumstances when a more precisely targetedassessments needs to be undertaken.The MHSWR (1999) require that employers record any group of employees who are identified asbeing especially at risk.New, Expectant and Breastfeeding Mo<strong>the</strong>rs <strong>Risk</strong> <strong>Assessment</strong> (appendix 7)The Management of Health and Safety at Work Regulations 1999 (MHSWR) regulations 16 – 18relate to ‘new, expectant or nursing Mo<strong>the</strong>rs’, as employees who are pregnant who have ‘givenbirth’ within <strong>the</strong> previous six months or who are breast feeding.‘Given birth’ means delivered a living child or, after 24 weeks of pregnancy, a stillborn child’.NB:It is <strong>the</strong> employee’s responsibility to notify <strong>the</strong> employer of her condition, i.e., that she is anew, expectant or nursing Mo<strong>the</strong>r. She should do this by producing a Doctor’s or Midwife’scertificate showing that this condition exists. Temporary staff should notify <strong>the</strong>ir Agency orBank that <strong>the</strong>y are covered by <strong>the</strong>se particular regulations. Before commencement ofemployment, <strong>the</strong> Agency should <strong>the</strong>n advise <strong>the</strong> <strong>Trust</strong> in writing of <strong>the</strong> condition.There is a requirement to assess any risk where <strong>the</strong>re could be a danger to <strong>the</strong> new, expectant ornursing Mo<strong>the</strong>r or her baby.It is not (legally) a Manager’s responsibility to attempt to make an assessment for a condition ofwhich <strong>the</strong>y are unaware. This said however, if it were suspected that an employee is pregnant<strong>the</strong>n it would be unwise to ignore <strong>the</strong> fact that <strong>the</strong> condition exists and has to be taken intoaccount.EU directives give a non-exhaustive list of agents for which <strong>Risk</strong> <strong>Assessment</strong> should be made onthis group of employees. This includesPhysical• Noise, Shocks• Vibration or movement• Extremes of cold or heat• Radiation (ionising and non-ionising)• Handling of loads entailing risks, particularly of a dorsolumbar nature• Movements or postures, travelling (inside or outside <strong>the</strong> establishment), mental andphysical fatigue and o<strong>the</strong>r physical burdens connected with <strong>the</strong> activities of <strong>the</strong>seworkersWhere <strong>the</strong>se agents could endanger <strong>the</strong> health of <strong>the</strong> pregnant woman, or her unborn child (<strong>Risk</strong>sfrom infectious or contagious disease in <strong>the</strong> context of <strong>the</strong> regulations are risks that are additionalto risks that a new or expectant Mo<strong>the</strong>r may be expected to be exposed to outside of <strong>the</strong>workplace).Page 13 of 70
Document Reference Code RM/006/09ChemicalControl of Substances Hazardous to Health (COSHH) records should be checked to see whe<strong>the</strong>rany substance that you are using could affect <strong>the</strong> health of <strong>the</strong> pregnant woman or her unbornchild. Pay particular attention to chemical marked as ‘mutagenic, teratogenic’ or with risk phrases61, 63 or 64.61 May cause harm to <strong>the</strong> unborn child63 Possible risk of harm to <strong>the</strong> unborn child64 May cause harm to breast fed babiesNB:Under <strong>the</strong> legislation, exposure of new, expectant or nursing Mo<strong>the</strong>rs to certain biologicaland chemical agents is PROHIBITED. These include:• Toxoplasmas and rubella virus (unless <strong>the</strong> pregnant workers are proved to beprotected against such agents by immunisation).• Lead and its derivatives, in so far as <strong>the</strong>se agents are capable of being absorbed by<strong>the</strong> human organism.If it is impossible to avoid <strong>the</strong>se three risks to <strong>the</strong>se workers, <strong>the</strong>n <strong>the</strong>re is a course of action thatmust be followed:• If <strong>the</strong> risk to <strong>the</strong> new or expectant Mo<strong>the</strong>r or her baby cannot be avoided you shouldfirst of all consider altering her working conditions or hours of work to see if you canremove <strong>the</strong> risk.• If this is not reasonable or it is found that <strong>the</strong> risk has not in any case been removed,<strong>the</strong>n <strong>the</strong> Manager must (subject to Section 46 of <strong>the</strong> Employment Protections(Consolidation) Act (EPCA) 1978) suspend that employee from work, until such time asis necessary to avoid such risk.Fur<strong>the</strong>r guidance update December 2002, on new and expectant Mo<strong>the</strong>rs is contained in New andexpectant Mo<strong>the</strong>rs at Work: A guide for employees HSG 122 (available from HSE Books 01787881165 £9.50 June 2003). The table of hazards identified in <strong>the</strong> EC Directive (92/85/EEC) onPregnant Workers is given in this publication along with <strong>the</strong> risks and ways to avoid <strong>the</strong>m.The following booklets, both of which cover <strong>the</strong> maternity suspension provisions are freelyavailable from DTI (tel: 0870 150 2500)PL705 – Suspension from work on medical or maternity groundsPL958 – Maternity rightsIt is also made clear in <strong>the</strong> closing statement of <strong>the</strong> Pregnant Workers Directive that ‘it is notintended in any way that pregnancy and childbirth should be equated with sickness’.<strong>Risk</strong> <strong>Assessment</strong> of Young Persons (appendix 8)The law requires all employers, including <strong>Cornwall</strong> Partnership NHS Foundation <strong>Trust</strong> to assess<strong>the</strong> risks to all employees including young workers such as those under 18 years old and workexperiencestudents.Page 14 of 70
Document Reference Code RM/006/09Why?Young workers are seen as being particularly at risk because of <strong>the</strong>ir possible lack of awarenessof risks and <strong>the</strong> immaturity.Who is a Young Person?Regulation 19 of <strong>the</strong> MHSWR 1999 cover not only employees under <strong>the</strong> age of 18 but above <strong>the</strong>minimum school leaving age but also children (i.e., those under <strong>the</strong> minimum school leaving age)who may do work experience.What does <strong>the</strong> employer need to do to comply?• Assess <strong>the</strong> risks to young people before <strong>the</strong>y start work• Take into account <strong>the</strong>ir inexperience and lack of training• Address <strong>the</strong> issues raised in <strong>the</strong> risk assessment• Provide information to parents of school age children about <strong>the</strong> risks and control measuresintroduced• Take into account <strong>the</strong> risk assessment in deciding if <strong>the</strong>re are any areas from where <strong>the</strong>young person should be prohibited<strong>Risk</strong> <strong>Assessment</strong>This individual assessment will look at <strong>the</strong> risks to <strong>the</strong> young person including:• The layout of <strong>the</strong> workplace/office environment including lighting• The nature and duration of exposure• The range of <strong>the</strong> work undertaken• The range of equipment used: computers, electrical appliances• The extent of health and safety training providedThis assessment should be carried out before <strong>the</strong> young person starts work. Please see<strong>Trust</strong> Health and Safety <strong>Policy</strong> for specific risks, avoidance strategies and restrictions.Fur<strong>the</strong>r guidance on young workers is contained in Young People at Work: A guide for employersHSG165 (available from HSE Books 01787 881165 £7.95 June 2003)<strong>Risk</strong> <strong>Assessment</strong>s of Display Screen Equipment (appendix 9)The Health and Safety (Display Screen Equipment) Regulations 1992 set legal standards for thosewho use computers for a significant part of <strong>the</strong>ir normal daily routine. However, <strong>the</strong> standards<strong>the</strong>y specify are good practice whe<strong>the</strong>r you use <strong>the</strong> computer for half and hour a day or sevenhours a day.The <strong>Trust</strong> recognises and fully accepts its duties and responsibilities and will ensure that:• A suitable and sufficient risk assessment of each workstation used by a ‘user’ is carriedout and reviewed annually.• Any identified risks to employees are reduced as far as is reasonably practicable.This guidance applies to all ‘users’ and <strong>the</strong>ir workstations but <strong>the</strong> standards set should also beapplied to workstations not used by ‘users’ where possible.Page 15 of 70
Document Reference Code RM/006/09The workstation should be risk assessed in conjunction with <strong>the</strong> ‘user’ concerned. Just adjusting<strong>the</strong> chair or monitor or re-arranging <strong>the</strong> desk can make <strong>the</strong> workstation a safer place to work. All‘users’ should be trained to ensure <strong>the</strong>y are aware of <strong>the</strong> hazards and what <strong>the</strong>y can do to improve<strong>the</strong>ir workstation. Eye tests are available from Occupational Health.Please use form as in appendix 9 and see <strong>the</strong> <strong>Trust</strong> Health and Safety <strong>Policy</strong> for fur<strong>the</strong>rinformation.<strong>Risk</strong> <strong>Assessment</strong> of Chemicals: Control of Substances Hazardous to Health (COSHH)(appendix 10)Complying with <strong>the</strong> COSHH Regulations is an ongoing process and every new, potentially harmful,substance must be assessed before it is used in <strong>the</strong> workplace.Having ga<strong>the</strong>red a list of substances used in <strong>the</strong> work area, an assessment of <strong>the</strong> risks to healthmust be made. The substances where <strong>the</strong> risks are trivial do not have to be recorded e.g., use ofair freshener in an officeWhere a basic assessment is not required, a product date sheet for <strong>the</strong> substance must be held in<strong>the</strong> department for reference in an emergency.For <strong>the</strong> majority of substances used within <strong>the</strong> <strong>Trust</strong>, a basic assessment will be sufficient but forthose considered high risk or where product date sheets are not available e.g., biological agents, anon standard assessment will need to be completed in conjunction with <strong>the</strong> basis assessment.For fur<strong>the</strong>r information see <strong>the</strong> <strong>Trust</strong> Health and Safety <strong>Policy</strong>Work EquipmentTo ensure that equipment standards are met a risk assessment must be carried out. This mustconsider <strong>the</strong> equipment, where it is being used and by whom. It should establish <strong>the</strong> actionneeded to meet <strong>the</strong> legal requirements and prevent accidents.For fur<strong>the</strong>r information see <strong>the</strong> <strong>Trust</strong> Health and Safety <strong>Policy</strong> and Medical Devices <strong>Policy</strong>Manual Handling <strong>Risk</strong> <strong>Assessment</strong> (appendix 11)The Manual Handling regulations require <strong>the</strong> <strong>Trust</strong> to assess any manual handling operations thatmay be hazardous and to take <strong>the</strong> necessary steps to prevent injuries.Please complete form as in appendix 11.For fur<strong>the</strong>r information see <strong>the</strong> <strong>Trust</strong> Health and Safety <strong>Policy</strong>/Manual Handling <strong>Policy</strong>Lone WorkingBoth <strong>the</strong> Health and Safety at Work etc Act 1974 (HASAWA) And <strong>the</strong> MHSWR 1999 place dutieson Managers/Supervisors to identify <strong>the</strong> hazards arising from working alone and ensure <strong>the</strong>re areadequate controls in place to minimise any risks.Actions required to ensure reduced risk to lone workers should form part of <strong>the</strong>Ward/Department/Directorate local working polices and ideally be documented and disseminatedto all staff that are affected.Page 16 of 70
Document Reference Code RM/006/09Please complete form as in appendix 12For staff at risk of violence and abuse in <strong>the</strong> workplace, please also refer to <strong>the</strong> <strong>Policy</strong> TherapeuticManagement of Violence and AggressionFalls/Environmental <strong>Assessment</strong>s (appendices 13 - 16)An annual assessment should be made of <strong>the</strong> environment in which you work for areas caring forpatients at high risk of falling, a specific falls environment assessment should be carried out.Where hazards are identified, <strong>the</strong>se should be addressed in <strong>the</strong> manner described in section 7.9 SummaryAccountabilityProcess• Overall responsibility for managing risk lies with <strong>the</strong> Chief Executive.• That responsibility is devolved down through <strong>the</strong> management structure to <strong>the</strong>Networks through <strong>the</strong> Executive Director of Delivery, Improvement/Executive Nurse.• On a day-to-day basis <strong>the</strong> Network/Service Manager/Modern Matron are responsiblefor ensuring that a rolling programme of clinical and non-clinical <strong>Risk</strong> <strong>Assessment</strong>s arecarried out, recorded and monitored.• Where control measures are required to reduce, or eliminate risks, <strong>the</strong> Network/ServiceManager/Modern Matron should ensure that appropriate action is taken.• Where identified risks are considered to be unacceptable, <strong>the</strong>se should be entered onto<strong>the</strong> Directorate/Corporate <strong>Risk</strong> Register as appropriate.All Wards and Department are required to carry out risk assessments within <strong>the</strong>ir area.• Each area should have representatives of all grades and disciplines to consider <strong>the</strong>activities within <strong>the</strong> area being assessed and identify <strong>the</strong> potential hazards that existei<strong>the</strong>r by process mapping or ‘thought shower’.• To prioritise <strong>the</strong> assessment process commence risk assessments on identified riskthat fall within <strong>the</strong> red and blue areas of <strong>the</strong> Matrix.• Identify who is at risk.• Identify any specific <strong>Risk</strong> <strong>Assessment</strong>s that will be required to comply with legislation(see section 8).• Each identified risk will be graded for its consequence and likelihood using <strong>the</strong> 5 x 5<strong>Risk</strong> Scoring Matrix (appendix 2).• Record <strong>the</strong> control measures already in place and any measures that are required tofur<strong>the</strong>r reduce or eliminate <strong>the</strong> risk• The <strong>Risk</strong> <strong>Assessment</strong> Record (appendix 1) and any supporting documentation should<strong>the</strong>n be escalated through <strong>the</strong> Network Management process to agree an action plan,any resources required and for ratification through <strong>the</strong> Directorate programme.• The Network/Service Manager/Modern Matron is responsible for ensuring that all staffare informed of <strong>the</strong> risks within <strong>the</strong>ir areas and <strong>the</strong> control measures put in place.Whilst <strong>the</strong>re is corporate responsibility, each individual also has a responsibility in law toidentify risk and take steps to control it.Page 17 of 70
Appendix 1 – <strong>Risk</strong> <strong>Assessment</strong> RecordDocument Reference Code RM/006/09Speciality: Ward / Dept:Brief description of physical location covered:Hazard, Problem or Concern:(Something which has <strong>the</strong> potential to cause harm/damage)<strong>Risk</strong>s(What has/will cause <strong>the</strong> hazard to be realised and what could <strong>the</strong> impact be if realised)Please identify one of <strong>the</strong> Corporate objectives which will be affected by <strong>the</strong> risk identified:Control Measures already in Place:(What is already in place to prevent <strong>the</strong> hazard being realised)Objective 1 – Achieve excellent service ratings from clients and regulatorsObjective 2 – Include clients, carers and members in service designObjective 3 – Develop our workforce to meet service needsObjective 4 – To achieve best value and generate a surplus to invest in our servicesObjective 5 – Diversify and develop services to increase income or meet needsObjective 6 – Provide services from high quality facilitiesObjective 7 – Promote green working and reduce travel, carbon and wasteObjective 8 – Work with our partners in our communities to create life opportunitiesAre <strong>the</strong> control measures in place adequate?YES/NO<strong>Risk</strong> Evaluation: (Please use <strong>the</strong> 5x5 scoring matrix to assess consequence, likelihood andPriority)Consequence 1 2 3 4 5 Likelihood 1 2 3 4 5 Priority L M H CPlease circlePeople affected Patients Staff Visitors Contractors O<strong>the</strong>rsName, Designation of person completing <strong>the</strong> risk assessment:Name:Designation:Date:Page 18 of 70
Document Reference Code RM/006/09Without fur<strong>the</strong>r control measures in place, is <strong>the</strong> identified risk:Acceptable?Unacceptable?What alternative options are <strong>the</strong>re that could be considered to reduce <strong>the</strong> risk?What is <strong>the</strong> preferred option to reduce this risk?Section 2 (to be processed through local network process for managing risk)Action Required By Whom Time Scale forcompletionCompletedResources Required: (Please include cost and recurring costs)If <strong>the</strong> above actions are taken, is <strong>the</strong> residual risk acceptable? YES/NOPlease recalculate <strong>the</strong> risk score with <strong>the</strong> recommended control measures taken into considerationConsequence 1 2 3 4 5 Likelihood 1 2 3 4 5 Priority L M H CPleasecircleThis <strong>Assessment</strong>’sPlease give detailsrecommended actions andpriorities are agreed/declined Position:Signature:Date:Who owns <strong>the</strong> risk identified?Please give detailsName:Position:At what level has this risk beenentered onto <strong>the</strong> <strong>Risk</strong> Register?Please give detailsDate for ReviewA copy of This <strong>Risk</strong> <strong>Assessment</strong> Record, Should be held locally and accessible to staff.A copy should be forward to <strong>the</strong> <strong>Risk</strong> Management Dept for <strong>the</strong> central library.Advice on <strong>Risk</strong> <strong>Assessment</strong> may be obtained from <strong>the</strong> <strong>Risk</strong> Management dept Ex 1019Page 19 of 70
Appendix 2 – <strong>Risk</strong> Scoring MatrixDocument Reference Code RM/006/09Table 1 Consequence Scores (C)Choose <strong>the</strong> most appropriate domain for <strong>the</strong> identified risk from left hand side of <strong>the</strong> table, <strong>the</strong>nwork along <strong>the</strong> columns in <strong>the</strong> same row to assess <strong>the</strong> severity of <strong>the</strong> risk on <strong>the</strong> scale of 1-5 todetermining <strong>the</strong> consequence score, which is <strong>the</strong> number given at <strong>the</strong> top of <strong>the</strong> column.Consequence score (severity levels) and examples of descriptors1 2 3 4 5Domains Negligible Minor Moderate Major CatastrophicImpact on <strong>the</strong> safety ofpatients, staff or public(physical/psychologicalharm)Quality/complaints/auditMinimal injuryrequiringno/minimalintervention ortreatmentNo time off workPeripheralelementtreatmentservicesuboptimaloforInformalcomplaint/inquiryMinor injury orillness, requiringminorintervention.Requiring timeoff work for 14 daysIncrease in length ofhospital stay by >15daysMismanagement ofpatient care with longtermeffectsNon-compliance withnational standards withsignificant risk topatients if unresolvedMultiplecomplaints/independentreviewLow performance ratingCritical reportIncident leading todeathMultiple permanentinjuriesorirreversible heal<strong>the</strong>ffectsAn event whichimpacts on a largenumber of patients.Totallyunacceptable levelor quality oftreatment/serviceGross failure ofpatient safety iffindings not actedonInquest/ombudsmaninquiryGross failure tomeet nationalstandardsHuman Resources/Organisationaldevelopment/staffing /competenceStatutory duty /inspectionsShort-term lowstaffing level thattemporarilyreduces servicequality (1day)Low staff moralPoor staffattendance formandatory/keytrainingSingle breech ofstatutory dutyUncertain delivery ofkey objectives/servicedue to lack of staffUnsafe staffing level orcompetence (>5 days)Loss of key staffVery low staff moraleNo staff attendingmandatory / keytrainingEnforcement actionMultiple breeches inNon-delivery of keyobjective/servicedue to lack of staffOngoing unsafestaffing levels orcompetenceLoss of several keystaffNo staff attendingmandatory training/key training on anongoing basisMultiple breeches instatutory dutyPage 20 of 70
statutory dutyReducedperformanceratingunresolvedifChallengingexternalrecommendations/ improvementnoticeDocument Reference Code RM/006/09statutory dutyImprovement noticesLow performance ratingCritical reportProsecutionComplete systemschange requiredZeroratingperformanceAdverse publicity /reputationBusiness objectives /projectsFinanceclaimsincludingRumoursPotential forpublic concernInsignificant costincrease /scheduleslippageLocal mediacoverage –short -termreduction inpublicconfidenceElements ofpublicexpectation nobeing met£10,000-£50,000 overproject budgetScheduleslippage< £10,000 £10,000-£50,000Local mediacoverage – longtermreduction inpublic confidence£50,000-£250,000 overproject budgetScheduleslippage£50,000-£250,000National mediacoverage with 3days service wellbelow reasonablepublic expectation.MP concerned(questions in <strong>the</strong>House)Total loss of publicconfidenceIncident leading>£500,000 overproject budgetSchedule slippageSchedule slippageKey objectives notKey objectives not met met£250,000-£500,000 >£500,000Service / businessinterruptionLoss/interruptionof >1 hourLoss/interruptionof >8 hoursLoss/interruptionof >1dayLoss/interruption of >1weekPermanent loss ofservice or facilityEnvironmental impactMinimal or noimpact on <strong>the</strong>environmentMinor impact onenvironmentModerate impacton environmentMajor impact onenvironmentCatastrophic impacton environmentTable 2 Likelihood score (L)What is <strong>the</strong> likelihood of <strong>the</strong> consequence occurring?The frequency-based score is appropriate in most circumstances and is easier to identify. It shouldbe used whenever it is possible to identify a frequency.Likelihood 1 2 3 4 5ScoreDescriptor Rare Unlikely Possible Likely Almost CertainFrequency This will Do not expect it Might happen Will probably Willprobably never to happen/recur or recur happen/recur undoubtedlyHow Often happen/recur but it is possible occasionally but it is not a happen/recurmight it/does ithappenit may do sopersisting issue possiblyfrequentlyPage 21 of 70
Table 3 <strong>Risk</strong> Scoring = Consequence x Likelihood (C x L)Document Reference Code RM/006/09LikelihoodConsequence 1 2 3 4 5Rare Unlikely Possible Likely AlmostCertain5 Catastrophic 5 10 15 20 254 Major 4 8 12 16 203 Moderate 3 6 9 12 152 Minor 2 4 6 8 101 Negligible 1 2 3 4 5For grading risk, <strong>the</strong> scores obtained from <strong>the</strong> risk matrix are assigned grades as follows:Instructions for use1 – 3 Low risk4 – 6 Moderate risk8 – 12 High risk15 – 25 Extreme risk1. Define <strong>the</strong> risk(s) explicitly in terms of <strong>the</strong> adverse consequence(s) that might arisefrom <strong>the</strong> risk.2. Use table 1 to determine <strong>the</strong> consequence score(s) (C) for <strong>the</strong> potential adverseoutcome(s) relevant to <strong>the</strong> risk being evaluated.3. Use table 2 (above) to determine <strong>the</strong> likelihood score(s) (L) for those adverseoutcomes. If possible, score <strong>the</strong> likelihood by assigning a predicted frequency ofoccurrence of <strong>the</strong> adverse outcome. If this is not possible, assign a probability to <strong>the</strong>adverse outcome occurring within a given time frame, such as <strong>the</strong> lifetime of a projector a patient care episode. If it is not possible to determine a numerical probability <strong>the</strong>nuse <strong>the</strong> probability descriptions to determine <strong>the</strong> most appropriate score.4. Calculate <strong>the</strong> risk score <strong>the</strong> risk multiplying <strong>the</strong> consequence by <strong>the</strong> likelihood:C (consequence) x L (likelihood) = R (risk score)5. Identify <strong>the</strong> level at which <strong>the</strong> risk will be managed within <strong>Cornwall</strong> Partnership NHSFoundation <strong>Trust</strong>, assign priorities for remedial action, and determine whe<strong>the</strong>r risks areto be accepted on <strong>the</strong> basis of <strong>the</strong> colour bandings and risk ratings, and <strong>Cornwall</strong>Partnership NHS Foundation <strong>Trust</strong>’s risk management system. Include <strong>the</strong> risk on<strong>Cornwall</strong> Partnership NHS Foundation <strong>Trust</strong>’s risk register at <strong>the</strong> appropriate level.Page 22 of 70
Appendix 3 – <strong>Risk</strong> RegisterDocument Reference Code RM/006/09NumberDateenteredon <strong>Risk</strong>RegisterDescription andsource of <strong>the</strong> of riskSeverityLikelihood<strong>Risk</strong>RateScoreDate lastmodifiedOwnerMitigatingaction and <strong>the</strong>ircostProgress onmitigatingactionResidualscoreR A GPage 23 of 70
Appendix 4 – Steps in doing a <strong>Risk</strong> <strong>Assessment</strong> FlowchartDocument reference code: RM/006/09Step 1Identify <strong>the</strong> hazardsStep 2Decide who might beharmed and howStep 3Evaluate <strong>the</strong> risk anddecide on precautionsStep 4Record your findingand implement <strong>the</strong>mStep 5Review yourassessment andupdate as necessaryPage 24 of 70
Appendix 5 – <strong>Risk</strong> Register ProcessDocument reference code: RM/006/09Ward/Office and Team Level
Corporate <strong>Risk</strong> Register > 15Document reference code: RM/006/09New Directorate <strong>Risk</strong> RegisterLearning Disabilities<strong>Risk</strong> RegisterAdult Mental Health<strong>Risk</strong> RegisterDrug & Alcohol Team<strong>Risk</strong> RegisterChildren’s Services<strong>Risk</strong> RegisterFinance<strong>Risk</strong> RegisterCHESS<strong>Risk</strong> RegisterBodmin Inpatient Unit(Less than 10)Longreach Inpatient Unit(Less than 10)North CMHT(Less than 10)West CMHT(Less than 10)Mid CMHT(Less than 10)Older Persons(Less than 10)Page 26 of 70
Appendix 6 – Examples/Hazards and <strong>Risk</strong>s, Associated <strong>Risk</strong>Document reference code: RM/006/09HazardSlip/Trip/FallsFalls from height/falling objectsCollision with objectsManual HandlingElectricityContact with chemicalsLone WorkingExamples/Hazards and <strong>Risk</strong>s, Associated <strong>Risk</strong>sFall of a person on <strong>the</strong> same levelFall of a person, object/materialBumps and BruisingBack, injuries, cuts, injury to jointsFire, shock, burnsDermatitis, burns, poisoningNo support/back up in situations which may arise e.g.,violence and aggression service userPage 27 of 70
Document reference code: RM/006/09Appendix 7a – <strong>Risk</strong> <strong>Assessment</strong> Checklist for ‘New and Expectant Mo<strong>the</strong>rs’GUIDANCE ON COMPLETING THIS FORMThis form is designed to determine <strong>the</strong> risks associated with pregnancy while at work, it appliesequally to a New, an expectant mo<strong>the</strong>r (unborn child) and <strong>the</strong> risks associated with new mo<strong>the</strong>rswho are breastfeeding on return to work.This form is designed to be used with all four stages of <strong>the</strong> risk assessment process. An initial riskassessment (Stage 1) should have been carried out in <strong>the</strong> workplace. This looks at <strong>the</strong> risks to allwomen of childbearing age and <strong>the</strong> results conveyed to all employees. This is a generic styleassessment, if this has not been done it should be completed before a stage risk assessment iscarried out.This form is also to be completed by <strong>the</strong> Manager of <strong>the</strong> expectant mo<strong>the</strong>r, upon notification that<strong>the</strong> employee is pregnant. (Stage 2 risk assessment) The hazards identified are to be noted onthis form and an action plan completed with <strong>the</strong> risk ratings is to be written up. The manager is toagree <strong>the</strong> action plan, its implementation and review dates with <strong>the</strong> employee at this assessment.The assessment is to be reviewed throughout <strong>the</strong> pregnancy, (Stage 3 risk assessment)because as <strong>the</strong> pregnancy develops new hazards are likely to develop as <strong>the</strong> expectant mo<strong>the</strong>r’shealth, shape and mobility changes.After <strong>the</strong> pregnancy and upon return to work a fur<strong>the</strong>r review is to be carried out, (stage 4 riskassessment) this is most important if <strong>the</strong> new mo<strong>the</strong>r is breastfeeding.Please tick <strong>the</strong> appropriate boxes adding fur<strong>the</strong>r information in <strong>the</strong> comment box.Boxes ticked ‘No’ may highlight concerns indicating a risk assessment and action arenecessary.Please contact <strong>the</strong> <strong>Risk</strong> & Safety Services Department Ext 2908 if you require fur<strong>the</strong>rguidancePage 30 of 70
Document reference code: RM/006/09HospitalDirectorateForenamesJob TitleDETAILS OF THE EXPECTANT, NEW OR BREASTFEEDING MOTHERPlace of Work(ward/dept/area)Work Tele No.SurnameSignatureDetails of <strong>the</strong> Assessor(s), <strong>the</strong> assessment dates and reviewsInitial <strong>Risk</strong> <strong>Assessment</strong>(stage 1) (date checklistand action plan firstcompleted)Specific <strong>Risk</strong> <strong>Assessment</strong>upon notification ofpregnancy (stage 2)Review <strong>Assessment</strong>during pregnancy (stage3)<strong>Assessment</strong> on return towork (stage 4)Forename Surname Signature Job Title DateChecklist 11. Physical HazardsDetermine if <strong>the</strong> employee is exposed to any of <strong>the</strong> hazards listed below, tick <strong>the</strong>appropriate box and <strong>the</strong>n elaborate in <strong>the</strong> comments box where you have answered ‘YES’to paint a word picturea) Is <strong>the</strong> employee exposed to(constant or excessive) heatabove ambient temperatures?CommentsInitialassessmentStage 1<strong>Assessment</strong>s duringpregnancy Stages2 and 3<strong>Assessment</strong>on return towork Stage 4Yes No Yes No Yes No Yes Nob) Is <strong>the</strong> employee exposed to(constant or excessive) coldbelow ambient temperatures?CommentsYes No Yes No Yes No Yes Noc) Is <strong>the</strong> employee exposed tonoise, ei<strong>the</strong>r constant orexcessive in <strong>the</strong> normal courseof <strong>the</strong>ir work?Yes No Yes No Yes No Yes NoPage 31 of 70
CommentsDocument reference code: RM/006/09d) Is <strong>the</strong> employee exposed toexcessive dust in <strong>the</strong> normalcourse of <strong>the</strong>ir work as a resultof a work process?CommentsYes No Yes No Yes No Yes Noe) Is <strong>the</strong> employee exposed toshock or vibration (particularlywhole body low frequency) in<strong>the</strong> normal course of <strong>the</strong>ir work?(NB:- this in particular applies tothose who drive on a regularbasis as part of <strong>the</strong>ir job)?CommentsYes No Yes No Yes No Yes Nof) Does <strong>the</strong> employee have to adoptany awkward postures or carry outany excessive movements that maycause physical and/or mentalfatigue in <strong>the</strong> normal course of <strong>the</strong>irwork? (NB:- pregnancy causes anincrease in girth that makes itsometimes awkward to adopt acomfortable position, retain balanceetc.)CommentsYes No Yes No Yes No Yes Nog) Is <strong>the</strong> employee exposed (orlikely to be exposed) to ionizingor non-ionising radiation in <strong>the</strong>normal course of <strong>the</strong>ir work?CommentsYes No Yes No Yes No Yes Noh) Does <strong>the</strong> employee or is <strong>the</strong>employee expected to carry outmanual handling tasks during<strong>the</strong> normal course of <strong>the</strong>ir work?CommentsYes No Yes No Yes No Yes Noi) Does <strong>the</strong> employee carry outany work where <strong>the</strong>y areexposed to Hyperbaricatmospheres?CommentsYes No Yes No Yes No Yes NoPage 32 of 70
Checklist 2Document reference code: RM/006/092. Chemical HazardsDetermine if <strong>the</strong> employee is exposed to any of <strong>the</strong> hazards listed below, tick <strong>the</strong>appropriate box and <strong>the</strong>n elaborate in <strong>the</strong> comments box where you have answered ‘YES’to paint a work picture. Guidance – Check your COSHH assessments, and/or hazard datasheets and/or check <strong>the</strong> labels on all containers/packaging.a) Is <strong>the</strong> employee exposed in<strong>the</strong> normal course of <strong>the</strong>ir workto any of <strong>the</strong> followingchemicals:-• Mercury,• Lead• Carbon MonoxideCommentsInitialassessmentStage 1<strong>Assessment</strong>s duringpregnancy Stages2 and 3<strong>Assessment</strong>on return towork Stage 4Yes No Yes No Yes No Yes Nob) Is <strong>the</strong> employee exposed in<strong>the</strong> normal course of <strong>the</strong>ir workto any substance absorbedthrough <strong>the</strong> skin?CommentsYes No Yes No Yes No Yes Noc) Is <strong>the</strong> employee exposed to oruses, handles, administersCytotoxic (Antimitotic) Drugs in<strong>the</strong> normal course of <strong>the</strong>ir workCommentsYes No Yes No Yes No Yes Nod) Is <strong>the</strong> employee in <strong>the</strong> normalcourse of <strong>the</strong>ir work to anysubstance labelled oncontainers/packaging asfollows:-• R40 possible of irreversibleeffects• R45 may cause cancer• R46 may cause heritablegeneric damage• R61 may cause harm to <strong>the</strong>unborn child• R63 possible risk of harm to<strong>the</strong> unborn child• R64 may cause harm tobreast fed babiesCommentsYes No Yes No Yes No Yes NoPage 33 of 70
Document reference code: RM/006/09e) Is <strong>the</strong> employee exposed in<strong>the</strong> normal course of <strong>the</strong>ir workto any substance labelled on<strong>the</strong> containers/packaging asTeratogenic or MutagenicCommentsYes No Yes No Yes No Yes Nof) Is <strong>the</strong> employee exposed toany fumes or vapors which arecreated or caused as part of awork processCommentsYes No Yes No Yes No Yes Nog) Does <strong>the</strong> employee work withany anes<strong>the</strong>tic gases Yes No Yes No Yes No Yes NoCommentsh) Is <strong>the</strong> employee exposed toany o<strong>the</strong>r than substancecovered by <strong>the</strong> COSHHregulationsCommentsYes No Yes No Yes No Yes NoChecklist 33. Biological HazardsDetermine if <strong>the</strong> employee is exposed to any of <strong>the</strong> hazards listed below, tick in <strong>the</strong>appropriate box and <strong>the</strong>n elaborate in <strong>the</strong> comments box where you have answered ‘YES’to paint a word picture. GUIDANCE:-a) Is <strong>the</strong> employee exposed in<strong>the</strong> normal course of <strong>the</strong>ir workto any of <strong>the</strong> following, morethan <strong>the</strong>y would be outside ofwork?• HumanCytomegalovirus(especially in children’sward)• Hepatitis B• Humanimmunodeficiency virus(HIV)• Listeria (especially foodworkers)• Human parovirusYes No Yes No Yes No Yes NoPage 34 of 70
• Rubella (GermanMeasles)• Varicella-zoster(Chickenpox)• Tuberculosis• HerpesCommentsDocument reference code: RM/006/09b) Is <strong>the</strong> employee exposed toany o<strong>the</strong>r bacteria or viruses in<strong>the</strong> normal course of <strong>the</strong>irwork, more than <strong>the</strong>y would beoutside of workList and CommentsYes No Yes No Yes No Yes Noc) Is <strong>the</strong> employee suffering fromany form of skin infectionCommentsYes No Yes No Yes No Yes NoChecklist 44. Hazards relating to working conditions and ergonomicsDetermine if <strong>the</strong> employee encounters any of <strong>the</strong> hazards listed below, tick in <strong>the</strong>appropriate box and <strong>the</strong>n elaborate in <strong>the</strong> comments box where you have answered ‘YES’to paint a word picture. GUIDANCE: -Consider <strong>the</strong> employees increasing size includingcomfort and balance.a) Does <strong>the</strong> employee work with oruse Visual Display Units (VDU’s)on a daily basis or as a significantpart of <strong>the</strong>ir job?CommentsYes No Yes No Yes No Yes Nob) Does <strong>the</strong> employee work inconfined or small areas or do<strong>the</strong>y visit patient’s homes, whichimpede movement due to <strong>the</strong>increased size of <strong>the</strong> expectantmo<strong>the</strong>r?CommentsYes No Yes No Yes No Yes Noc) Does <strong>the</strong> employees PersonalProtective Equipment (PPE) ifpreviously issued still fit correctlyYes No Yes No Yes No Yes NoPage 35 of 70
and give <strong>the</strong> same degree ofprotection it? (NB:- Uniformshould also be considered)CommentsDocument reference code: RM/006/09d) Is <strong>the</strong> employee exposed tonauseating smells, which mayaffect <strong>the</strong>m in pregnancy?CommentsYes No Yes No Yes No Yes Noe) Does <strong>the</strong> job entail long periodsof standing/adverse posture orinvolve a job where Dexterity,agility, co-ordination, speed ofmovement or reach may beimpaired because of increasingsize?CommentsYes No Yes No Yes No Yes Nof) Does <strong>the</strong> job entail visiting orattending patients whose home orworkplace presents hazards notnormally encountered in ahealthcare premise? If “yes”please list.CommentsYes No Yes No Yes No Yes Nog) Does <strong>the</strong> job entail visiting orattending patients outside of <strong>the</strong>healthcare environment who maybe presupposed to violentbehavior?CommentsYes No Yes No Yes No Yes Noh) Given that hazards exist in <strong>the</strong>workplace or are inherent in a job:are <strong>the</strong>ir any additional or unusualhazards that exist or are createdsolely due to a women’spregnancy and/or size? i.e.-Balance, access or vision.CommentsYesNo Yes No Yes No Yes NoPage 36 of 70
Checklist 5Document reference code: RM/006/095. Free formatPlease add fur<strong>the</strong>r identified hazards and specific comments as necessaryHazard IdentifiedComments/ActionGeneral CommentsPage 37 of 70
Document reference code: RM/006/09Appendix 8 – Young Persons <strong>Risk</strong> <strong>Assessment</strong>Managers Overall Health And Safety ChecklistMANAGERS YES NO REMARKS/COMMENTSHas a person/department been nominated to be <strong>the</strong>overall contact for young workers, including those onwork experienceWhere students are on a work experience placement,has effective liaison been established with <strong>the</strong>placement organisers, including arrangements forregular monitoring and reporting of incidents/nearmisses/ill healthHave ‘suitable and sufficient’ risk assessments beencarried out prior to <strong>the</strong> student joiningHave any additional control measures for youngpeople clearly been identifiedHave risk assessments taken into account of anyspecial health and safety needs which young workersmay have as a result, for example, of any physicaland learning disabilities, or health issues such asallergies, asthma and respiratory problems, heartdisease, diabetes, colour blindness, deafness or <strong>the</strong>use of prescription medicinesHave work activities which young people should beprohibited from undertaking been clearly identifiedHave necessary steps been taken to isolate or makesafe dangerous tools, plant equipment or substancesHave any necessary arrangements for personalsafety and freedom from sexual harassment, violenceand aggression or bullying been consideredHave parents or guardians been informed of risksand control measuresHave arrangements been made for appropriatesupervision and training, including induction beenmadeHave work tasks for young people been properlydefined and explained? Do young people understandwhat is required of <strong>the</strong>m in order to protect <strong>the</strong>ir ownsafety and health and that of o<strong>the</strong>rsHave young workers been provided with appropriateinformation about hazards, risk and precautionsCompleted by nameDatedSignature of ManagerNB:This form should be filed with <strong>the</strong> risk assessment and checklists so as to present acomplete record for that individual.A copy of this form is to be forwarded to <strong>the</strong> <strong>Risk</strong> Management DepartmentPage 38 of 70
Document reference code: RM/006/09Appendix 8a – Managers/Student Combined Plan Of Work Record Form And Checklist ForYoung PersonsInstructions for use:This checklist is to be shared with individual students by <strong>the</strong> Manager and sets out what <strong>the</strong>Manager expects from <strong>the</strong> student, it is to be completed before <strong>the</strong> student joins and again after aperiod of days/weeks after <strong>the</strong> student joins <strong>the</strong> <strong>Trust</strong> as an employee or for work experience. It isto be signed by both Manager and student and is to be kept on file.Name of Young PersonPlace of Work(Ward/Dept/Area)Length of placement From ToDate of BirthSiteStatus (delete as applicable)Employee / Work experienceName of ManagerAs a Manager, you have a particular responsibility for <strong>the</strong> young people who work for you. Alwaysremember that <strong>the</strong>y are more vulnerable than experienced members of staff, in particular, early on,you need to discuss with <strong>the</strong>m <strong>the</strong> following items.Date of <strong>Risk</strong> <strong>Assessment</strong>Brief Job DescriptionSpecific RestrictionsProhibition of <strong>the</strong> use of specific equipmentProhibition of specified processes etcActivities only to be undertaken with supervisionRestricted areasDone(enter date)To be completed by Manager(enter <strong>the</strong> specific issues that relate to thisindividual)Contact ArrangementsRoutine contactsIn case of problemsName and role of MentorName of Safety RepresentativePage 39 of 70
Document reference code: RM/006/09Emergency evacuation procedure Done To be completed byManagerLocation of fire exitsLocation of fire extinguishers and break glasspointsAction of discovering a fireInform student of testing regimeAction on hearing fire alarmEmphasise do not use a lift in <strong>the</strong> event of a fireEmphasise that it is dangerous to block fire doorsand fire exitsFirst Aid and Incident/Near Miss Reporting Done To be completed byManagerWhat to do in <strong>the</strong> event that you need First AidHow to call an AmbulanceHow to report an Incident/Accident/Near MissJob SafetyHazards and Precautionsa) Chemical substances including body fluidsHazardspresent in jobSafety overviewgiven to studentSpecificadditionaltrainingrequiredb) Noisec) Extremes of temperature (heat/cold)d) Electricale) Lifting and Handlingf) Machinery and Equipmentg) Display Screen Equipmenth) Housekeepingi) Site Transportj) Exposure to potentially violent oraggressive people including patientsk) O<strong>the</strong>r (please state)Page 40 of 70
Document reference code: RM/006/09Hazard Reporting, unsafe acts and conditions Done To be completed by ManagerJob Specific Hazards(please specify)DoneTo be completed by ManagerDSE Users Done To be completed by Manager<strong>Risk</strong>s and Precautions outlinedTraining Done To be completed by ManagerAdditional training required not specifiedMiscellaneous Done To be completed by ManagerConfidentially disclosureCash and ValuablesPersonal Gifts or RewardsPersonal Possessions, SecurityIdentificationA copy of this form is to be forwarded to <strong>the</strong> <strong>Risk</strong> Management DepartmentPage 41 of 70
Tasks to be completed/workplace, dates and activitiesDocument reference code: RM/006/09Plan of Work(set by <strong>the</strong> Manager)Timescale Student Activities DateCompletedI confirm that <strong>the</strong> checklist and plan of work form have been completed, that <strong>the</strong> student has seen<strong>the</strong> form and checklist, agrees and understands itSignedStudentSignedManagerDatedNB:This form should be filed with <strong>the</strong> risk assessment and checklists so as to present acomplete record for that individual.Page 42 of 70
Document reference code: RM/006/09Appendix 8b – Example guidelines for <strong>Risk</strong> <strong>Assessment</strong>s for Managers of Young PersonsInstructions for use:This guideline document is designed to assist Managers when <strong>the</strong>y carry out <strong>the</strong>ir <strong>Risk</strong><strong>Assessment</strong>s on young people and work experience students, to highlight areas that <strong>the</strong>y shouldincluded in <strong>the</strong>ir General <strong>Risk</strong> <strong>Assessment</strong>s and <strong>the</strong> main risks that will be encountered. It is notcomprehensive as individual areas will have slightly different risks dependant on where <strong>the</strong> studentis working, however it seeks to inform Managers and students of a set of common risks throughoutthat can be used in completing <strong>the</strong> document shown in Appendix 2 and <strong>the</strong> actual Combined <strong>Risk</strong><strong>Assessment</strong> and Action Plan form at Appendix 5Ref Young Persons Task StatementNo.1.1 Students must not set, reset or in any wayinterfere with any medical devices unless under<strong>the</strong> direct supervision of a Registered Nurse1.1 Students must not carry out jobs that involveworking at heights1.2 Students must not participate in or observe anyemergency resuscitation procedures1.2 Students must not participate in, or assist with<strong>the</strong> moving or physical supporting of patients1.3 Students should at all times work under <strong>the</strong>supervision of a trained/qualified member of staffwho is competent in <strong>the</strong> task being undertaken3.2 When handling patients, universal precautionsshould be taken i.e. gloves and aprons to beworn4.1 Students must be briefed and ensure that <strong>the</strong>yknow <strong>the</strong> location of emergency escape routesand fire exits4.2 Students must be briefed and ensue that <strong>the</strong>yknow <strong>the</strong> location of fire extinguishers and breakglass points4.3 Students must be informed on <strong>the</strong> action to betaken on discovering a fire6.1a Students if handling body fluids must takeuniversal precautions and wear gloves andaprons5.1 Students must be informed of <strong>the</strong> first aidfacilities in <strong>the</strong>ir designated place of workMain <strong>Risk</strong>sAccidental start-up of machinery, injuryto hands from moving machinery parts,inappropriate adjustments giving rise tomalfunction and injuryFalls, slips from stools and ladders etcresulting in injuryPersonal distress, TraumaPhysical injury to student and PatientLack of knowledge/experience leadingto unsolicited errors resulting in injury topatients and <strong>the</strong>mselvesInfection Control and personalprotection against chemicals and o<strong>the</strong>rhazardous substancesIncreased risks to patients, visitors andstaff in escaping from fire, injury,damage to property, litigation andmedia coverageIncreased risk of fire spread and injuryto patients, visitors and staff, damage topropertyIncreased risk of fire spread and injuryto patients, visitors and staff, damage topropertyInfection controlNot knowing who <strong>the</strong>ir First Aiders orAppointed persons are, not knowing <strong>the</strong>Location of First Aid Kits, injury<strong>Risk</strong>s remain undiscovered leading to5.3 Students must be informed of how to report anincident in accordance with <strong>Trust</strong> policyinjury, Litigation8.1 Students must attend all safety related Lack of knowledge leading tomandatory trainingunsolicited errors8.1 Students must attend Induction training Lack of knowledge, unsolicited errors9.1 Students must be informed not to disclose Release of confidential medicalconfidential patient related information, gained as information, Litigation, media interestPage 43 of 70
a result of <strong>the</strong>ir placement to anyone o<strong>the</strong>r thanthose within <strong>the</strong> immediate care team9.2 Students must ensure that due care is taken ofpatients belongings and that <strong>the</strong> presence ofcash and valuables is brought to <strong>the</strong> attention ofa member of <strong>Cornwall</strong> Partnership NHSFoundation <strong>Trust</strong> staff9.3 Students must not accept any personal gifts orrewards of any kind from patients or <strong>the</strong>ir visitors.Any such offers must be reported to <strong>the</strong> person incharge9.4 Students must ensure that <strong>the</strong>ir personalpossessions are secured9.5 Students must ensure that <strong>the</strong>y are issued withidentificationDocument reference code: RM/006/09Complaints, Media attentionPosition compromised, complaints,litigation and media attentionTheft, Position Compromised,complaints, litigation and mediaattentionSecurity breachPage 44 of 70
Document reference code: RM/006/09Appendix 8c – Example guidelines for <strong>Risk</strong> <strong>Assessment</strong>s for Managers of Catering Staff,Young PersonsRef Young Persons Task StatementNo.1.1 Students must not set, reset or in any wayinterfere with any machinery unless under <strong>the</strong>direct supervision of a qualified member of staff1.1 Students must not carry out jobs that involveworking at heights1.1 Students must not use/clean food slicers, mixers,food processors or Potato chippers1.1 Students must not use any form of WasteCompactors1.1 Students must not be given <strong>the</strong> task of using,cleaning or draining (deep) fat fryers1.2 Students must not participate in or assist with <strong>the</strong>moving or physical supporting of Heavy loads1.2 Students must not be given <strong>the</strong> task of De-boningmeat1.3 Students should at all times work under <strong>the</strong>supervision of a trained/qualified member of staffwho is competent in <strong>the</strong> task being undertaken3.1 Students must be made aware of <strong>the</strong> need towear protective equipment when handling food3.2 Students must be made aware of what types ofprotective equipment <strong>the</strong>y need to wear for <strong>the</strong>various tasks <strong>the</strong>y will be engaged in4.1 Students must be briefed and ensure that <strong>the</strong>yknow <strong>the</strong> location of emergency escape routesand fire exits4.2 Students must be briefed and ensue that <strong>the</strong>yknow <strong>the</strong> location of fire extinguishers and breakglass points4.3 Students must be informed on <strong>the</strong> action to betaken on discovering a fire5.1 Students must be informed of <strong>the</strong> First Aidfacilities in <strong>the</strong>ir designated place of work5.3 Students must be informed of how to report anincident in accordance with <strong>Trust</strong> policy6.1 Students must know if it part of <strong>the</strong>ir jobexpectations how to use <strong>the</strong> dishwasher6.1 Students must know if it part of <strong>the</strong>ir jobexpectations how to clean floorsMain <strong>Risk</strong>sAccidental start-up of machinery, injuryto hands from moving machinery parts,inappropriate adjustments giving rise tomalfunction and injuryFalls, slips from stools and ladders etcresulting in injuryAccidental start-up of machinery, injuryto hands from moving machinery partsInjury from contact with movingmachinery, entrapmentFire, burns, spillages, inappropriatewaste disposalPhysical injury from manual handlingSevere cut or stab wounds from knivesLack of knowledge/experience leadingto unsolicited errors resulting in injury topatients and <strong>the</strong>mselvesFood contaminationInfection Control and personalprotection against chemicals and o<strong>the</strong>rhazardous substancesIncreased risks to patients, visitors andstaff in escaping from fire, injury,damage to property, litigation andmedia coverageIncreased risk of fire spread and injuryto patients, visitors and staff, damage topropertyNot knowing what to do, possible injuryor loss of lifeNot knowing who <strong>the</strong>ir First Aiders orAppointed persons are, not knowing <strong>the</strong>Location of First Aid Kits, use of blueplasters<strong>Risk</strong>s remain undiscovered leading toinjury, LitigationManual Handling, Use of cleaningmaterials, slips, trips and falls oncrowded or wet floorsManual Handling, Use of cleaningmaterials, slips, trips and falls from wetfloors and seepages/spillagesPage 45 of 70
Document reference code: RM/006/096.1 Students must know <strong>the</strong> correct procedures fordisposing of refuse and o<strong>the</strong>r rubbish6.3 Students must know <strong>the</strong> correct procedures for<strong>the</strong> handling and use of corrosive cleaningmaterials, including oven cleaners if this is part of<strong>the</strong>ir job6.3 Students who assist in preparing hot food mustbe aware of <strong>the</strong> handling risks involved6.3 Students who assist in preparing and servingfood must be made aware of <strong>the</strong> correct practicefor using tools and serving food8.1 Students must attend all safety relatedmandatory training9.2 Students must ensure that due care is taken ofcash handling and o<strong>the</strong>r valuables entrusted to<strong>the</strong>ir care and control and any discrepancy isbrought to <strong>the</strong> attention of a member of <strong>Cornwall</strong>Partnership NHS Foundation <strong>Trust</strong> staff9.3 Students must not accept any personal gifts orrewards of any kind from patients or visitors. Anysuch offers must be reported to <strong>the</strong> person incharge9.4 Students must ensure that <strong>the</strong>ir personalpossessions are secured9.5 Students must ensure that <strong>the</strong>y are issued withidentificationCorrect types of colour-coded bagsused in hospitals- wrongly disposed ofwaste, manual handling, cuts frombroken glassChemical burns to skin or eyesBurns, scolds, slips, trips and falls,Manual Handling, SpillagesCuts from sharp knives, slips, trips andfalls, Manual Handling, SpillagesLack of knowledge leading tounsolicited errorsComplaints, Media attentionPosition Compromised, complaints,litigation and media attentionTheft, Position Compromised,complaints, litigation and mediaattentionSecurity breachPage 46 of 70
Document reference code: RM/006/09Appendix 8d – Young Persons combined <strong>Risk</strong> <strong>Assessment</strong> and Action Plan formHospital Ward/dept Assessors Name <strong>Assessment</strong>DateGroup Tel No Signature Review DateACTIVITIESRISK ASSESSMENT SUMMARYACTION PLANSNAME OF LEAD OR RESPONSIBLE PERSONSDept SerialNo. <strong>Risk</strong>Register NoHAZARD ORCONCERNPlease describeRISK OR HARMPlease add descriptionand include details of<strong>the</strong> Number of personsaffectedState details ofexisting controlsin place tomitigate riskCurrentNumericscoresLik.Sev.StateTotalCurrent<strong>Risk</strong>ScoreUsing5x5MatrixACTIONS TO BEIMPLEMENTEDState details of additionalactions/controls requiredto eliminate/reduce riskTargetDeadlineforactionand/orcontrolsin placeResidualNumericscoresLik.Sev.State TotalResidual <strong>Risk</strong>Score Once <strong>the</strong>Actions And/OrAdditionalControls Are In PlaceDate ActualDeadline thataction and/orcontrols arein placeNB:Please ensure that you use <strong>the</strong> same checklist with this <strong>Risk</strong> <strong>Assessment</strong> form, o<strong>the</strong>rwise you will not be able to check back on <strong>the</strong> risksidentified. Also, please continue on a separate sheet if appropriate.Page 47 of 70
Appendix 9 – Display Screen Equipment Initial ChecklistDocument reference code: RM/006/09GUIDANCE NOTESThis form is designed to assist in an initial display screen equipment checklist being undertaken toidentify hazards and risks when working in a computer related environment.Please tick <strong>the</strong> appropriate box. Following which fur<strong>the</strong>r risk assessment and action may benecessary.Please contact <strong>the</strong> <strong>Risk</strong> Management Department Ext 1019 if you require fur<strong>the</strong>r guidance.Directorate Dept/Office Contact Ext:Name of User: JobTitle: ChecklistDate:1. THE SCREENa. Is <strong>the</strong> screen image stable and flicker free Yes NoCommentsb. Does <strong>the</strong> screen have a brightness/contrast control Yes NoCommentsc. Does <strong>the</strong> screen have a tilt and swivel base Yes NoCommentsd. Is <strong>the</strong> screen free from reflection and glare Yes NoCommentse. Have you been provided with a filter screen Yes NoComments2. THE KEYBOARDa. Is it possible to easily alter <strong>the</strong> angle of <strong>the</strong> tilt of <strong>the</strong> keyboard Yes NoCommentsb. Is <strong>the</strong>re adequate space at <strong>the</strong> front of <strong>the</strong> keyboard to provide support for<strong>the</strong> hands and wristsCommentsYesNoc. Are <strong>the</strong> characters on <strong>the</strong> keys easily readable Yes NoCommentsd. Can you find a comfortable keying position Yes NoCommentsPage 48 of 70
Document reference code: RM/006/093. OTHER EQUIPMENTa. Has a document holder been provided Yes NoCommentsb. Have you been provided with a mouse-mat Yes NoCommentsc. Have you been provided with a wrist-rest Yes NoComments4. THE ENVIRONMENT - Space, Lighting, Reflection & Glare, Noise, Temperature, Humiditya. Is <strong>the</strong>re enough space, with storage, to enable easy access to <strong>the</strong>Yes NoworkstationCommentsb. Is <strong>the</strong>re adequate lighting for all tasks Yes NoCommentsc. Are desks lamps supplied where necessary Yes NoCommentsd. Are blinds or curtains fitted at windows Yes NoCommentse. If so, do <strong>the</strong>y prevent reflection and glare Yes NoCommentsf. Is noise considered a problem in <strong>the</strong> workplace Yes NoCommentsg. If yes, has <strong>the</strong> noise source been resited or moved away from <strong>the</strong>workstationCommentsYesNoh. Is <strong>the</strong> temperature maintained at a level which ensures user comfort Yes NoCommentsi. Have sources of excess heat been suitably controlled or eliminated. Yes NoComments5. FURNITUREPage 49 of 70
Document reference code: RM/006/09a. Is <strong>the</strong> desk or work surface sufficiently large enough to accommodate Yes Nocomputer, keyboard printer and o<strong>the</strong>r necessary work equipmentCommentsb. Is <strong>the</strong>re enough space under <strong>the</strong> work surface to enable <strong>the</strong> user toachieve a comfortable position and move legs freelyCommentsYesNoc. Is <strong>the</strong> worksurface free of glare and reflection Yes NoCommentsd. Does <strong>the</strong> chair have 5 castors Yes NoCommentse. Does <strong>the</strong> seat have adjustable height, backrest and tilt facility Yes NoCommentsf. Are you able to adjust <strong>the</strong> chair comfortably Yes NoCommentsg. With chair adjusted are your feet flat on <strong>the</strong> floor Yes NoComments6. OPERATOR COMPUTER INTERFACEa. Is <strong>the</strong> computer software user friendly Yes NoComments7. JOB DESIGNa. Does <strong>the</strong> job allow for work activities away from <strong>the</strong> computer screen Yes NoCommentsb. Are you encouraged to take short frequent breaks away from <strong>the</strong> screen Yes NoCommentsc. Does your computer work involve work of a repetitive nature with <strong>the</strong>keyboardCommentsYesNod. Does your computer work involve work of a repetitive nature with <strong>the</strong>mouseCommentsYesNoPage 50 of 70
Document reference code: RM/006/098. INFORMATION & TRAININGe. Have you received information and/or documentation relating to safeuse of working with display screen equipmentCommentsYesNof. Are you aware of <strong>the</strong> <strong>Trust</strong> arrangements for vision screening via <strong>the</strong>Occupational Health DeptCommentsYesNog. Have you received training on possible hazards of working with displayscreen equipmentCommentsYesNoh. Have you received training on how to adjust <strong>the</strong> position of display screenequipment and <strong>the</strong> workstationCommentsYesNoi. Are you encouraged to take short frequent breaks away from <strong>the</strong> screen Yes NoCommentsj. Do you think training on working with display screen equipment would bebeneficialCommentsYesNoDSE Checklist carried out by (please print)DesignationDept/OfficeDateContact Tel: ExtPage 51 of 70
Document reference code: RM/006/09Appendix 10 – Control of Substances Hazardous to Health Regulations 2004 (COSHH) Inventory and Summary List of COSHH <strong>Assessment</strong>sDirectorate:- Assessors:- <strong>Assessment</strong> Date:- Actual Site(Ward/department./specific area):-Location:-Review date:-ItemNo.Substance Quantity Freq. OfUseDuration ofExposurePersonsExposedHazardsto HealthOverall<strong>Risk</strong>RankingNumerical riskrankingL,M,H,E Impact LikelihoodPage 52 of 70
Appendix 11 – Manual Handling Practical <strong>Assessment</strong> FormDocument Reference code: RM/006/09Name:Trainer:Ward/Dept:Designation:Manager:Technique1 Lifting/handling inanimate objects2 Assisting people to stand with:• transfer belt• turntable3 • Correct use of electric beds.• Bed rails.4 Assisting people to move in bed:• turning with slide sheet• sitting forward• moving up/down with:• slide sheet• Removing of slide sheet.5 Transfer bed to chair and backusing passive hoist.Safely getting a fallen patient upfrom <strong>the</strong> floor.6 Use of passive hoist with:• standard sling• de luxe sling• access sling• long seat sling• Disposable sling7 Use of standing hoist with:• Standing sling Deluxe• Transport sling8 Wheelchairs9 Techniques relevant to work baseTheoryOnly(please tick)CorrectlyDemonstrated(please tick)Y N N/AElements requiringDevelopmentCOMMENTSCompetence has been demonstrated in <strong>the</strong> above techniques as indicated.Trainer Signature:Date:Candidate Signature:Date:NB: The candidate was competent at <strong>the</strong> time of <strong>the</strong> assessment. It is <strong>the</strong> Manager’s responsibilityto ensure workplace compliance and <strong>the</strong> candidate’s responsibility to adhere to <strong>the</strong>ir training.Staff member to have six monthly competence assessment in regard to equipment used.53 of 70
Document Reference code: RM/006/09Appendix 11a – Manual Handling Practical <strong>Assessment</strong> Form: Inanimate Load & PhysicalInterventionName:Ward/Dept:Trainer:Designation:Manager:Technique1 High <strong>Risk</strong>Movement use of physicalintervention2 BoxSquatHalf squatOne kneeUsing chair/stool etc3 Trolley4 Chair wheelchair5 Orange / laundry Bag6 Sack/bin sack7 Team lifting8 O<strong>the</strong>rBathingWalking (supported)Household choresTheory Only(please tick)CorrectlyDemonstrated(please tick)Y N N/AElements requiringDevelopmentCOMMENTSCompetence has been demonstrated in <strong>the</strong> above techniques as indicated.Trainer Signature:Date:Candidate Signature:Date:NB:The candidate was competent at <strong>the</strong> time of <strong>the</strong> assessment. It is <strong>the</strong> Manager’sresponsibility to ensure workplace compliance and <strong>the</strong> candidate’s responsibility toadhere to <strong>the</strong>ir training.54 of 70
Document Reference code: RM/006/09Appendix 11b – Manual Handling Guidance for Completing a Generic / Individual <strong>Risk</strong><strong>Assessment</strong>GUIDANCE NOTES - This form is designed to assist in identifying manual handling hazards and<strong>the</strong> associated risks in your workplaceCHECKLISTTHE TASKS - THIS INCLUDES LIFTING / TRANSFERING / MANOUVERINGDo <strong>the</strong>y involve:a. Holding loads away from trunk?b. Twisting / stooping?c. Reaching upwards?d. Long carrying distance?e. Strenuous pushing or pulling?f. Unpredictable movement of loads?g. Repetitive handling?h. Insufficient rest or recovery period?I. A rate of work over which you have no controlTHE LOADS - INANIMATE / ANIMATE:a. Heavy?b. Bulky / unwieldy?c. Difficult to grasp e.g. wet / slippery?d. Unstable / unpredictable?e. Harmful e.g. sharp edges / hot to touch?THE WORKING ENVIRONMENT - are <strong>the</strong>re:a. Contraints on posture?b. Is <strong>the</strong> flooring in poor condition?c. Variations in floor levels?d. Hot, cold or humid conditions?e. Poor lighting conditions?f. Ergonomics (is space adequate / limited)?g. Is <strong>the</strong>re appropriate equipment for use?55 of 70
Appendix 11c – Client/Patient Manual Handling <strong>Assessment</strong> FormDocument Reference code: RM/006/09CLIENT NAME: …………………………..B NUMBER: ………………………….DATE: ……………………………….Is <strong>the</strong> patient/client independently ambulant? Yes NoIf yes please sign and place in <strong>the</strong> assessment section of notes.Complete this form if needs of patient/ client changeIs <strong>the</strong> patient/client non ambulant?If yes please complete <strong>the</strong> following form and add to <strong>the</strong> assessment section of notes.Is <strong>the</strong> patient/client Bariatric? Yes NoIf yes please complete <strong>the</strong> following form and add to <strong>the</strong> assessment section of notes.Section ABed Mobility score Sitting Balance scoreIndependent 0 Independent 0Independent wi<strong>the</strong>quipment1 Supervision only 2Supervision only 2 Help+1 with equipment 4Supervision wi<strong>the</strong>quipment3 Help+1 no equipment 5Help+1 with equipment 4 Help+2 or more wi<strong>the</strong>quipmentHelp+1 no equipment 5 Help+2 or more noequipment68Help+2 or more wi<strong>the</strong>quip.6 Unable to assist 10Help+2 or more no equip. 8Unable to assist 9Transfers score Walking scoreIndependent 0 Independent 0Independent wi<strong>the</strong>quipment1 Independent wi<strong>the</strong>quipment1Supervision only 2 Supervision only 2Supervision wi<strong>the</strong>quipment3 Supervision wi<strong>the</strong>quipment3Help+1 with equipment 4 Help+1 with equipment 4Help+1 no equipment 5 Help+1 no equipment 556 of 70
Document Reference code: RM/006/09Help+2 or more wi<strong>the</strong>quip.6 Help+2 or more wi<strong>the</strong>quip6Help+2 or more no equip. 8 Help+2 or more no equip 8Unable to assist 10 Unable to assist 10Score range <strong>Risk</strong> level Colour0 – 5 = Low risk Green6 – 34 = Medium risk Amber35 and above=High riskRedReport for section ADates score colour Designation SignatureComplete client /patient handling Action planComplex handling issues should be discussed with Physio’s and/or OT’s Manual handlingAdvisor as appropriateSection BTo be completed if any of <strong>the</strong> following would cause a problem when being supported withmoving and handling.Psychological score Special <strong>Risk</strong>s ScoreCommunication difficulties 5 Major surgery 10Unpredictable 10 Sedated/drowsy 10Challenging physicalbehaviour5 History of falls 1010 Pain restricting movement 10Bariatric / Difficult to handlepatients10Report for section BScore range <strong>Risk</strong> level Colour0 – 5 = Low risk Green6 – 34 = Medium risk Amber35 and above=High riskRed57 of 70
Dates score colour Designation SignatureDocument Reference code: RM/006/09BARIATRIC CLIENT/PATIENT MANUAL HANDLING ACTION PLANHEIGHTDocument <strong>the</strong> following – Handling method, equipment andNumber of staff required for safest practice.BODY MASS BODY TYPE CIRCUMFRENCE OF THE WAISTINDEXDATEHANDLINGACTIVITYEQUIPMENT Handlingbelt/slidingsheets/boards. Zimmerframe etc.,Bed ManoeuvresSIZE (SLING) S, M,LBariatricNo. OF STAFFREQ’DChair to Bed/Bed toChairTurn over in bedSit up from lyingMove back up bedDaily ActivitiesSittingSit to standFrom chairWalkingBathing (In & out ofbath)DressingSpecial requirements specific to areaTransport58 of 70
Document Reference code: RM/006/09EquipmentNamesignaturePhysio<strong>the</strong>rapyreferral.Occupational<strong>the</strong>rapy referral.Manual HandlingAdvisorSIGNATUREDATE59 of 70
Document Reference code: RM/006/09Appendix 11d – Manual Handling6 MONTHLY PRACTICAL ASSESSMENT OF COMPETENCE ON EQUIPMENT SPECIFIC TOPRACTICENameBaseDate of <strong>Assessment</strong>Equipment Used Date Staff Signature AuthorisationReview DateStaff SignatureAuthorisationManual HandlingTrainer’s SignatureNBOne completed this form must be brought to Compulsory Practical update60 of 70
Document Reference code: RM/006/09Appendix 12 – Lone Workers pre <strong>Risk</strong> <strong>Assessment</strong> Checklist: Working alone in buildingsStaff exposed to <strong>the</strong> risk i.e. group & numberWard/ DepartmentSiteChecklist completed byDate completedReview DateMain Issues of concern Yes NoDo staff work alone?Do staff work outside normal office hours?Do staff meet with clients or patients in isolated locations?Is <strong>the</strong>re enough security provision?Is <strong>the</strong>re poor access to <strong>the</strong> building?Do staff activities involve working in confined spaces?Do staff activities involve handling dangerous substances?Control measures for consideration Yes NoDo you provide joint working for high risk activities?(i.e.: in confined space and with dangerous substances)Do you use entrance security systems?( i.e.: digital locks or swipe cards)Is <strong>the</strong>re a security lighting around access points and parking areas?Have you installed panic buttons linked to manned locations?Do you use reporting check- in systems?Do you use two-way radios or o<strong>the</strong>r communication systems?Do staff have information and training on basic personal safety?Are staff trained in strategies for preventing and managing violence?Do staff have access to form for reporting incidents or near misses andappreciate <strong>the</strong> need for this procedure?Are your existing control measures adequate?If NO what modifications or additional actions are necessary?12345NOTE:If you have identified a risk associated with this work activity please complete<strong>the</strong> <strong>Trust</strong> <strong>Risk</strong> assessment Form.61 of 70
Appendix 12a – Lone Workers Checklist: Domiciliary visitsStaff exposed to <strong>the</strong> risk i.e. group & numberWard/ DepartmentSiteChecklist completed byDate completedReview DateDocument Reference code: RM/006/09Main Issues of concern Yes NoDo staff carry out visits in high-risk locations (i.e. areas with high crime rates)?Do staff carry out visits in isolated rural area?Do staff visit unfamiliar clients or relatives?Do staff visit a high-risk or unstable or unpredictable client group?Do staff carry out visits during unsocial hours?Do staff carry valuables or drugs?Control measures for consideration Yes NoDo you provide accompanied visits when <strong>the</strong>re are concerns about safety?Do you include potential or known risk factors in referral documents and careplans?Do you share risk information with o<strong>the</strong>r professional and agencies?Are <strong>the</strong>re systems for monitoring staff whereabouts and movements for regularlyreporting to base?Have you issued mobile phones?Have you issued personal attack alarms?Do staff have information and training on basic personal safety?Are staff trained in strategies for preventing and managing violence?Do staff carry forms for reporting incidents or near misses andappreciate <strong>the</strong> need for this procedure?Are your existing control measures adequate?If NO what modifications or additional actions are necessary?12345Note: If you have identified a risk associated with this work activity please complete <strong>the</strong><strong>Trust</strong>s <strong>Risk</strong> <strong>Assessment</strong> Form.62 of 70
Document Reference code: RM/006/09Appendix 12b – T.M.A.V. Training Needs <strong>Assessment</strong>Is <strong>the</strong> member of staff in contact withService Users, Relatives or GeneralPublic?NOTMVA Training need is ConflictResolution TrainingYESIs <strong>the</strong> member of staff working on aninpatient unit in Mental Health orTreatment unit in Learning Disabilities?NOTMVA Training need is PersonalSafety CourseIs <strong>the</strong> member of staff part of <strong>the</strong>nursing team?NOTMVA Training need is PersonalSafety Course (appropriate restraintcourse is optional with Managersagreement)Training need isPhysical InterventionsEldercareOlder Person (MH)What type of unit do<strong>the</strong>y work on?LDTMVA Training need isPersonal Safety andPhysical InterventionsAdultTMVA Training need is Personal Safetyand Teamwork Restraint course63 of 70
Document Reference code: RM/006/09Appendix 13 – Initial Falls <strong>Assessment</strong>5 QUESTION SCREENING TOOL/OVERVIEW FALLS SCREENING TOOLPatients Full Name:Patients DOB:Ward:CR Number1. Is <strong>the</strong>re a history of any fall in <strong>the</strong> last 12 months? (Include this fall) YES/NO*Number of falls in <strong>the</strong> last 12 months……………..2. Is <strong>the</strong> person on four or more medications per day? YES/NO*Number of medications per day…………………….3. Does <strong>the</strong> person have a diagnosis of stroke or Parkinson’s disease? YES/NO4. Does <strong>the</strong> person report any problems with <strong>the</strong>ir balance? YES/NO5. Is <strong>the</strong> person unable to rise from a chair of knee height without using YES/NO<strong>the</strong>ir arms?Date &Time of Last Fall:Full Name of AssessorAssessor Base:Assessor Signature:Job Title:Department/Ward:DateIf <strong>the</strong> patient scores three or more ‘YES’ answers a multi-factorial risk assessment must becompleted.64 of 70
Document Reference code: RM/006/09Appendix 14 – Multi factorial Falls <strong>Risk</strong> <strong>Assessment</strong>MULTIFACTORIAL FALLS RISK ASSESSMENT TOOLPatientNameCRDOB1. History of Falling - history of one or more falls in past year? Yes/NoPrompts: Ask history of falls, frequency, context and characteristicsFall Indoor or outdoors?History of dizziness, L.O.CHistory of recurrent fallsACTION: Refer to Falls Service2. Number of Medications - takes >4 medications per day? Yes/NoPrompt: Identify type of medication being prescribed.Including eye drops.ACTION: Needs Medication review3. Central Nervous System Suppressants - use of 1 or more for more than twoweeks?Yes/NoPrompts: Identify type of medication being prescribed i.e. hypnotics,antidepressants, sleeping pills and antipsychoticsACTION: Needs Medication Review4. Alcohol Intake - >1 unit alcohol per day Yes/NoPrompts: Advise regarding immediate and long term fall risk due to dulling of neurologicalcapacity from alcoholACTION: Refer For Advice to GP or Practice Nurse5. Postural Hypotension present i.e. 20mmHg drop on lying to standing ordizziness on standing/sitting up?Yes/NoPrompts: Teach to prepare for movement by simple lower limb muscle contractions and toStabilise self after changing position and before walkingACTION: Needs medical review6. Vision - difficulty in reading, cannot recognise an object across <strong>the</strong> room,recently started wearing bifocals?Yes/NoPrompts: Raise awareness regarding risks due to blurring and difficulty in judging distance65 of 70
Advise disuse of bifocals or care when first wearing <strong>the</strong>mAdvise to concentrate on walking and be deliberate/ cautious,especially in new situations and on uneven surfacesACTION: Needs eye testDocument Reference code: RM/006/097. Hearing – has difficulty hearing conversational speech? Yes/NoPrompts: Teach family about visual cueingUse of amplifiers, earphones and hearing loops.ACTION: Needs hearing examination8. Walking/Gait – is unsteady on feet, shuffles or takes uneven steps/ishousebound?Yes/NoPrompts: Check walking aid and observe gaitCheck feet and footwearTimed Get Up and Go >15secACTION: Needs Physio<strong>the</strong>rapy assessmentNeeds foot care and footwear advice9. Functional ability – Reports decreased function and confidence? Yes/NoPrompts: Observe transfers and functional activitiesSit to stand >3 secs?Identify problem activitiesFear of falling?ACTION: Needs <strong>the</strong>rapy assessment10. Balance – needs to hold onto furniture, requires stick or frame? Yes/NoPrompts: Can patient stand unsupported for 30 secs?Patient reports feeling unsteady / dizzy?ACTION: Needs physio<strong>the</strong>rapy assessment11. Environmental Hazards on <strong>the</strong> ward – untidy, slip/trip hazards? Yes/NoPrompts: Is bed space uncluttered? Does patient require low bed?Check chair height/ sitting balance. Consider bed rails.Is call bell within easy reach?ACTION: Maintain clear environment & access to call bell. Considerspecialist equipment. Consider moving to easily observable area.12. Lower urinary tract (LUT) - has difficulty getting to <strong>the</strong> toilet in time? Yes/NoPrompts: Has overwhelming urgency to void?Gets wet before reaching <strong>the</strong> toilet?66 of 70
Document Reference code: RM/006/09Needs to go frequently by day?Is woken up from sleep with desire to void?ACTION: Needs continence assessment and advice leaflet13. Mental state – Has memory problems or low mood? Yes/NoPrompts: History of forgetfulness, confusion or loss of confidence?Poor concentration?ACTION: Needs 6 CIT Dementia assessmentNeeds 4 item Geriatric Depression Scale14. Osteoporosis <strong>Risk</strong>? Yes/NoPrevious low trauma fracture?Corticosteroid use? > 7.5mg prednisolone for 6 months or moreFamily history of osteoporosis? – especially maternal hip fractureHeight loss or Kyphosis?Low body weight? BMI
Document Reference code: RM/006/09Appendix 15 – Protocol for <strong>the</strong> use of <strong>the</strong> Multi factorial Falls <strong>Risk</strong> <strong>Assessment</strong> ToolFor use by Health and Social Care professionals for all patients / clients who score 2 or more on<strong>the</strong> 5 question screening tool1. History of fallingAccurate history of fall and circumstances will help inform decision to refer to falls service:Loss of Consciousness, recurrent or unexplained falls, history of facial injury or dizzinessassociated with change of position indicates need for medical review in Falls Clinic.Consider type of dizziness: Light headed = CardiovascularUnsteady = CerebrovascularVertigo = ? VestibularInformation available: ‘Staying Steady’ Help <strong>the</strong> Aged2. Number of medicationsNote potential discrepancy between medication prescribed and compliance by patient.Culprit medications for falls include diuretics, antihypertensives and CNS suppressants.Information available: ‘Managing your Medicines’ Help <strong>the</strong> Aged3. Central Nervous System SuppressantsCheck dosage and time of day it is taken4. Alcohol intakeBe mindful of patients self assessment of alcohol units consumed5. Postural HypotensionPatient procedure:1. Lie patient down for 15 minutes2. Stand patient up – take 2 nd reading3. Maintain standing for 3 minutes – take 3 rd readingNote symptoms such as light headedness6. VisionOver 60’s are eligible for a free eye test every 2 years at opticiansInformation available: ‘Better Sight’ Help <strong>the</strong> Aged7. HearingNote viral or ear infections may cause vestibular symptoms.Information available: ‘Better Hearing’ Help <strong>the</strong> Aged8. Walking / GaitObserve for discontinuous steps, difference in step length, deviation from path or shuffling68 of 70
Document Reference code: RM/006/09Timed get up and go Test (TGUG) components:1 Getting up from chair2 Walking 3 metres3 Turning4 Walking 3 metres (return)5 Sitting downIdentify foot care routine, note abnormalities of skin and nails. Look for general flexibility offoot and ankle. Foot wear checks – note size, whe<strong>the</strong>r supportive and safe fit.Information available: ‘Keeping Mobile’ and ‘Fitter Feet’ Help <strong>the</strong> Aged9. Functional AbilityNote potential difference between perceived and actual functional ability.Sit to stand taking more than 3 seconds indicates lower limb dysfunction.Use 0-10 scale to record self assessment of fear of falling 0 = no confidence10 = usual for you10. BalanceTimed unsupported steady stand (TUSS) of less than 30 seconds indicates balanceproblems and impaired postural stability.11. Environmental HazardsSmall modifications of <strong>the</strong> environment such as provision of rails and removal of tripshazards / loose mats can reduce risk of falls. Encourage self assessment of <strong>the</strong>environment and activities to consider potential risk.Information available: ‘Safety in your Home’ Help <strong>the</strong> Aged12. Lower Urinary Tract Infection (LUTI)Urgency - overwhelming urge to voidFrequency - voiding more than 8 times per dayNocturia - woken from sleep more than twice per weekSee ‘ Management of frail and older person with Urinary Incontinence’ <strong>Cornwall</strong>Continence Promotion ServiceInformation available: ‘Bladder and Bowel Weakness’ Help <strong>the</strong> Aged13. Mental StateCognitive Impairment Test (6 CIT) (straightforward questions that can be conversationalra<strong>the</strong>r than feel like a test). The higher <strong>the</strong> score <strong>the</strong> more impairment is indicated.Geriatric Depression Scale (4GDS)See ‘Shared Care Pathway for People with Dementia’ Appendix 4 pages 36 and 37<strong>Cornwall</strong> Partnership NHS Foundation <strong>Trust</strong> – Older Peoples Mental Health ServicePublic Internet Site14. Osteoporosis <strong>Risk</strong>Reinforce links between bone health and falls and fracture risk.Information available:‘Healthy Bones’ and ‘Healthy Eating’ Help <strong>the</strong> AgedNational Osteoporosis Society’ www.nos.org.uk69 of 70
Appendix 16 – Minimising <strong>the</strong> <strong>Risk</strong> of Falls – Environmental <strong>Assessment</strong>Document Reference code: RM/006/09Ward/Dept:Name of Assessor:Date of <strong>Assessment</strong>:Job title:<strong>Assessment</strong>Are bed heights at <strong>the</strong> correct height for eachpatient?Are chair heights <strong>the</strong> correct height for patients?Is <strong>the</strong>re effective lighting?Are call bells within patient reach?Are patient belongings within easy reach?Has action been taken to maximise observation ofall patients? E.g. position of nurse baseAre patient bed areas free from clutter/equipmentwhich may form obstacles?Are bed brakes on?Is <strong>the</strong> pathway from bed to toilet free fromobstaclesAre bathrooms/toilets clearly labelled?Is <strong>the</strong> floor safe and dry?Have patients got appropriate footwear?How long does it take for a call bell to beanswered? (No. of minutes)Yes, No,N/AAction taken/Comments70 of 70