1. health and fitness

Service Delivery Health and Safety
Risk Assessment Policy
Document Summary
To ensure a coordinated approach towards clinical, environmental, health and safety and
service delivery risk assessment.
DOCUMENT NUMBER
POL/002/023
DATE RATIFIED
15/04/2013
DATE IMPLEMENTED
April 2013
NEXT REVIEW DATE
April 2015
ACCOUNTABLE DIRECTOR
Director of Performance Improvement
and Company Secretary
POLICY AUTHOR
Safety, Risk and Security Manager
Important Note:
The Intranet version of this document is the only version that is maintained.
Any printed copies should therefore be viewed as “uncontrolled” and, as such,
may not necessarily contain the latest updates and amendments.
TABLE OF CONTENTS
1
Scope
.......................................................................................................... 4
2
Introduction ......................................................................................................... 4
3
Statement of Intent .............................................................................................. 4
4
Definitions .......................................................................................................... 4
4.1 HAZARD ......................................................................................................... 4
4.2 RISK .............................................................................................................. 4
4.3 RISK ASSESSMENT .......................................................................................... 5
4.4 CONTROL MEASURE ........................................................................................ 5
4.5 RISK REGISTER ............................................................................................... 5
4.6 ‘REASONABLY PRACTICABLE’............................................................................ 5
4.7 ‘SUITABLE AND SUFFICIENT’ ............................................................................. 5
4.8 ‘REASONABLY FORESEEABLE’........................................................................... 5
5
Duties
5.1
5.2
5.3
5.4
5.5
6
.......................................................................................................... 5
CHIEF EXECUTIVE............................................................................................ 5
EXECUTIVE DIRECTORS ................................................................................... 6
MANAGERS ..................................................................................................... 6
SAFETY, RISK & SECURITY MANAGER ................................................................ 6
SAFETY, RISK & SECURITY CO-ORDINATOR ........................................................ 7
Arrangements for conducting service delivery health and safety risk
assessments ....................................................................................................... 7
6.1
6.2
6.3
6.4
6.5
6.6
6.7
RISK ASSESSMENT PROCESS ........................................................................... 7
RECORDING OF RISK ASSESSMENTS ................................................................. 7
REVIEW AND MONITORING OF RISK ASSESSMENTS .............................................. 7
RISK REGISTERS ............................................................................................. 8
ORGANISATIONAL OVERVIEW OF RISK................................................................ 8
RISK-ASSESSORS............................................................................................ 8
RISK ASSESSMENTS REQUIRED UNDER SPECIFIC LEGISLATION AND/OR TO COMPLY
WITH STATUTORY / MANDATORY REQUIREMENTS ....................................................... 8
7
Training
........................................................................................................ 11
8
Monitoring Compliance with this Policy ............................................................. 12
9
References/ Bibliography .................................................................................. 13
10 Related Trust Policy/Procedures ....................................................................... 13
Appendix 1 - Risk Assessment Process Flowchart .................................................. 14
Identify Hazards ................................................................................................ 14
Identify People and/or Services at Risk ............................................................. 14
Consider the Potential Risks ............................................................................. 14
Identify Existing Control Measures .................................................................... 14
Grade the Risk .................................................................................................. 14
Calculate the risk grading .................................................................................. 15
Further Actions to Reduce Risk (Risk Treatment Action Plan) .......................... 16
Hierarchy of Risk Controls ................................................................................ 16
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Approved 15/04/2013
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Appendix 2 - Ligature Point/Strangulation Risk Assessment Methodology & Protocol .
........................................................................................................ 18
Appendix 3 - Statutory/Mandatory Risk Assessments .............................................. 21
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1
SCOPE
This policy applies to all work activities, environments, and service areas of the
Trust, with the exception of clinical risk issues relating directly to the care and
treatment of individual patients, which are addressed through the Trust’s policy for
clinical risk assessment.
2
INTRODUCTION
It is a requirement of Regulation 3 of The Management of Health and Safety at Work
Regulations 1999 (as amended), that employers carry out a suitable and sufficient
assessment of the risks to health, safety and welfare of their employees or anybody
who may be affected by the employer’s undertakings.
3
STATEMENT OF INTENT
In accordance with the requirements of the Health and Safety at Work Act 1974, the
Management of Health and Safety at Work Regulations 1999 (as amended), and the
Trust’s Risk and Safety Strategy and Policy, the Trust will implement a
comprehensive risk assessment process to identify and evaluate risks to the health
safety and welfare of staff and others, risks that may affect the Trust’s ability to
deliver effective and quality services, and also risks to the achievement of the Trust’s
objectives. The Trust will operate a system for continually managing and monitoring
identified risks, with a view to eliminating risks where possible, or if this is not
possible, to managing them at the lowest reasonably practicable level of risk.
4
4.1
DEFINITIONS
Hazard
Any procedure, task, object, product, work environment, situation or other
circumstance with the potential to cause harm, damage or loss to people, property or
assets. It is also any barrier that could impact upon the ability of the Trust to deliver
quality and effective services or achieve its objectives
4.2
Risk
A combination of the likelihood of a hazard materialising / occurring, and the
consequences of it doing so, i.e. the potential outcome of the hazard, (nature of
injury, damage, loss or effect on service delivery)
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4.3
Risk Assessment
A consideration of the likelihood that the harm, damage or loss will actually occur,
taking into account the measures that are already in place to minimize or prevent
exposure to the hazard, and the consequences should it occur.
4.4
Control Measure
Any action or precaution taken to eliminate or minimise the likelihood of a hazard
materialising, and/or to eliminate or reduce the adverse consequences if it does so.
4.5
Risk Register
A list of all identified risks, compiled in a format that enables comparison and
prioritization of issues, otherwise known as the Risk Profile of the organization.
4.6
‘Reasonably Practicable’
The standard, under the Management of Health and Safety at Work Regulations
1999 (as amended), to which risks must be managed. ‘Reasonably practicable’
means balancing the ‘cost’ of taking action (in financial costs, time costs other
resourcing implications) against the benefits of taking the identified action. If the
‘cost’ outweighs the benefit that will be gained then the action is deemed to be not
reasonably practicable
4.7
‘Suitable and Sufficient’
In order for a risk assessment to be deemed ‘suitable and sufficient’, risk
assessments must identify all reasonably foreseeable issues that could affect the
health safety and welfare of individuals. The assessment must be documented in a
clearly understandable and unambiguous manner, it must be communicated to those
exposed to the risk, and it must be regularly reviewed.
4.8
‘Reasonably foreseeable’
A risk is ‘reasonably foreseeable’ if it is easily imaginable, or predictable that the
hazard, or risk issue will occur. Incident history or other local or national benchmark
data could be used to determine how foreseeable a situation is to occur.
5
5.1
DUTIES
Chief Executive
The Chief Executive has overall responsibility for ensuring suitable and sufficient risk
assessments are undertaken throughout the Trust. The Chief Executive delegates
the duty to implement this policy through Executive Directors to Local Managers.
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5.2
Executive Directors
It is the responsibility of Executive Directors to ensure this policy is implemented
throughout their Directorate.
5.3
Managers
Managers at all levels within the organisation are responsible for ensuring:Risk assessments are undertaken and recorded for all service areas within
their remit.
A continual process for hazard identification and subsequent risk
assessment in implemented within their service area.
Ensure a local Risk Register is maintained for their area of responsibility.
Prepare specific Locality/Departmental Policies and Guidelines to ensure all
necessary risk assessments are carried out in liaison with appropriate
identified relevant advisers where necessary.
Authorise, implement and monitor appropriate risk management control
measures within their designated area(s) and scope of responsibility.
Seek assistance from senior management and Trust specialist advisers,
where appropriate.
Ensure that Directors and senior managers are notified of significant risks
where current control measures are considered potentially inadequate.
Ensure that all staff are made aware of the risks within their work
environment, understand their personal responsibilities, and are given the
necessary information and training to enable them to undertake effective risk
management practices and are practising in an effective, competent and
safe manner.
Ensure staff are supported and listened to when speaking up about risk or
safety issues.
5.4
Safety, Risk & Security Manager
The Trust’s Safety Risk & Security Manager will provide regular performance reports
and information to Executive Directors and Trust governance committees; and keep
the Trust’s arrangements for compliance with statutory requirements in relation to
risk assessment of health and safety and service delivery issues under regular
review. The Trust’s Safety, Risk & Security Manager will ensure that training and
on-going support in conducting risk assessments is available to managers and staff
at all levels;
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5.5
Safety, Risk & Security Co-ordinator
The Trust’s Safety, Risk & Security Coordinator will provide training and on-going
support in conducting risk assessments to managers and staff at all levels;
6
6.1
ARRANGEMENTS FOR CONDUCTING SERVICE DELIVERY HEALTH AND
SAFETY RISK ASSESSMENTS
Risk Assessment Process
Risk assessment is a step by step process of identifying potential hazards,
considering the possible consequences of those hazards, identifying who may be
affected by them, then identifying and implementing control measures to prevent
damage, injury, loss or harm from occurring. Risks that cannot be eliminated must
be controlled as far as reasonably practicable.
Actions identified to reduce or further control risks will be identified within risk
assessments and will form part of an organisation wide action plan to reduce and
manage risks. Progress with identified actions will be managed and monitored by
local managers in accordance with the Trust’s Risk and Safety Strategy and Policy.
All risks will be formally assessed using the Trust’s established 5 x 5 risk grading
matrix as described within the Trust’s Risk & Safety Strategy & Policy. All service
delivery health and safety risks will be recorded using the Ulysses risk assessment
database which is accessible via the intranet (otherwise known as the ‘online tool’).
Please refer to Appendix 1 for detailed guidance on the risk assessment process,
including the grading matrix, and also a flowchart showing links with risk registers.
Recording of Risk Assessments
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6.2
Risk assessments must be documented in a clearly understandable and
unambiguous manner, stating the actual management practices that are operated.
All service delivery health and safety risk assessments will be recorded on the
‘online risk assessment tool’, which is accessible via the intranet. Risk assessments
must be entered onto the database at the local level by Local Managers (or a person
they designate this task to). Risk assessments entered onto the online tool populate
the Trust’s risk registers.
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6.3
Review and Monitoring of Risk Assessments
All risk assessments must be reviewed, and where necessary updated. The time
between reviews is dependent on the nature of the risk and subject matter of the risk
assessment. As a minimum risk assessments must be reviewed at least annually or:
When the nature of the work activity / environment / risk source changes.
After an accident, case of ill health or dangerous occurrence relating to the
identified hazard.
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Developments in work practices or management arrangements suggest the
assessment may no longer be valid.
Monitoring of reported incidents and near misses highlights areas of concern
with findings of risk assessment.
Identified actions to reduce or control risk further have been undertaken or
completed.
Risk Registers
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6.4
The Trust operates a tiered system of Risk Registers; Local, Locality and Corporate
Registers. All risk assessments recorded on the online risk assessment tool
automatically populate Local and Locality Registers. Risks entered on the Corporate
Risk Register must first have Board Level approval. Please refer to the Trust’s Risk
and Safety Strategy and Policy for further information regarding Risk Registers and
Governance arrangements relating to the Corporate Risk Register.
Organisational Overview Of Risk
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6.5
In accordance with the Trust’s Risk and Safety Strategy and Policy, a combination of
Local risk registers (which will be reviewed at least annually), the Corporate Risk
Register, the Assurance Framework, analysis / data reports from the Ulysses risk
database, together with annual and other performance reports will be used by the
Board, Governance Quality & Risk Committee, Clinical Governance and relevant
subgroups of these Committees, to gain an organisation wide overview of risk within
the organisation. Reports regarding risk assessment performance will be presented
to the Corporate Fire Health Safety & Security Committee at each meeting and also
to the Governance Quality & Risk Committee at least annually.
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6.6
Risk-Assessors
Risk assessors must have an understanding of the hazard and its impacts and
knowledge of the work activity / service delivery area being assessed. Any individual
who experiences difficulties in completing a risk assessment should contact the
Safety, Risk & Security Co-ordinator for advice
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6.7
Risk Assessments Required Under Specific Legislation and/or To Comply
With Statutory / Mandatory Requirements
The Management of Health and Safety at Work Regulations 1999 (as amended), as
well as other specific health and safety legislation, require risk assessments to be
undertaken for particular risk issues or work tasks. Whilst not an exhaustive list, the
most commonly encountered of these are stated below. A full list of risk
assessments required by the Trust where appropriate to a service or department is
available in Appendix 3. Managers will ensure that where any of these risks are
present in their ward/team/department, an appropriate risk assessment is
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undertaken. If in any doubt, managers should contact the Safety, Risk & Security Coordinator for advice.
1.1.1.1.1.7 Likel
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New & Expectant Mothers
A ‘new’ or ‘expectant’ mother is a woman who is pregnant or who has given
birth within the previous six months, or who is breast-feeding a child. Please
refer to the Trust’s policy on New and Expectant Mothers in the Workplace
(POL/002/013) for more detailed information regarding conducting a new or
expectant mother risk assessment.
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A ‘Young Worker’ is any person who has not reached the age of eighteen is a
‘young worker’. Please also refer to the Trust’s policy on Risk Assessment of
Young Persons at Work (POL/002/014).
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Young Workers
Risk assessments must be undertaken on all Display Screen Equipment
workstations to ensure they are sufficient to meet the needs of the individual,
and to ensure the health, safety and welfare of staff who are required to use
DSE as part of their job. Please refer to the Trust’s policy on the Safe Use of
Display Screen (POL/002/021).
Control of Substances Hazardous to Health (COSHH)
Risk assessments must be undertaken for all work activities involving
substances that fall under the remit of the Control of Substances Hazardous to
Health Regulations 1995. Please refer to the Trust’s COSHH policy
(POL/002/039) for further information and advice.
Display Screen Equipment
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Fire
In accordance with the Regulatory Reform (Fire Safety) Order 2005, all
premises occupied by the Trust must have a valid fire risk assessment. Fire risk
assessments will be undertaken by the Trust’s Officers in accordance with the
Trust’s Fire Safety Policy)POL/002/022).
Manual Handling
Risk assessments must be undertaken for tasks that involve a person to lift,
pull, push, or carry objects, including a person, in accordance with the Health
and Safety (Manual Handling Operations) Regulations 1998. The Trust’s
Safety, Risk & Security Co-ordinator, Manual Handling Officers, and the
network of Manual Handling Key Workers, work together to ensure the
requirements of these Regulations are being met. Refer to the Policy and
Procedure for Manual Handling (POL/002/030) for further information
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Risk assessments must be undertaken wherever the staff have employees who
work alone. Please refer to the Trust’s policy for Lone Working (POL/002/057)
for further information and advice.
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Lone Working
‘Environmental Risk Assessments’ is a phrase commonly used to describe risks
associated with the physical work environment, for example heating, lighting,
access control/security, protection of assets, conditions of floors, etc. This
policy encompasses all such ‘environmental’ risks. Risk assessments for these
issues must be documented in accordance with the detail contained within this
policy.
Stress
Risk assessments must be undertaken where hazard identification has
identified stress as a significant risk factor. Further guidance and information on
conducting risk assessments for stress related issues can found in Trust policy
on Stress at Work (POL/004/024).
‘Environmental’ Risk Assessments
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Security Risks
The term ‘Security’ includes situations where there may be risk of injury, harm,
damage or loss to staff, patients, visitors as well as to Trust property,
equipment, resources and other assets resulting from violence & aggression,
criminal damage or other unlawful act. Security risks must be identified and
recorded in accordance with this policy. Further information on the identification
and management of security risks is contained within the Trust Security Policy
(POL/002/015). Refer to Trust Policy for the Prevention and Management of
Violence and Aggression (POL/001/008), and also Policy for Lone Working
(POL/002/057) in relation to the risk assessment and management of risks of
violence and aggression.
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Slips, Trips and Falls including Falls from Height
Please refer to Trust Prevention and Management of Slips Trips and Falls in
Clinical and Non Clinical Settings Policy (POL/001/048) for information and
guidance on the assessment and management of slips trips and falls risks in
both clinical and non-clinical settings. That policy includes information and
guidance on assessment of falls from height.
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‘Individual-Specific’ Risk Assessments
There may be occasions when a risk assessment is requested or necessary
due to concerns over the health, safety or wellbeing of an individual staff
member, for example due to a disability or illness. In these instances the
manager is advised to contact the Safety, Risk & Security Co-ordinator for
advice on how to conduct such an assessment. It may also be appropriate for
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the HR Department to be consulted. The records of this type of assessment
must be recorded in the individual staff-member’s personnel file, and not on the
online risk assessment system.
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Ligature Points / Strangulation Risks
Due to the nature of the patients in the Trust’s care, there will always be a risk
of suicide by patients. However, when individual assessments, care plans and
ward environmental risks are managed effectively, the risk of suicide is reduced
as far as reasonably practicable. In order to assess inpatient ward
environments for ligature points and strangulation risks, the Trust has
developed a ligature risk assessment methodology, which is based upon a 3stage calculation relating to propensity of patients towards using ligatures or
strangulation methods as a means of self-harm, the level of observations in
patient occupied areas, and the type of ligature point / strangulation method in
question. This risk assessment methodology can be found at Appendix 2.
Ligature point /strangulation risk assessments are only required to be
undertaken in inpatient areas and will be completed annually. An entry must be
made on the online risk assessment system to acknowledge a ligature point
risk assessment has been undertaken. This should identify the main areas for
concern, but the actual detail of the ligature risk assessment will be held on
separate documentation that should be held on the ward. The maximum final
calculation sum for this type of risk assessment is 100 (as opposed to 25 using
the standard 5x5 risk matrix). When entering a record of the ligature risk
assessment onto the online system, the highest score on the completed
ligature risk assessment should be divided by 4 to enable the level of risk from
ligature issues to be assessed on a par with other risks faced within the Trust.
7
TRAINING
Mandatory training associated with risk assessment is included in the Trust’s
Training Needs Analysis. Attendance at training is managed in accordance with the
Learning and Development Policy.
The Safety, Risk & Security Co-ordinator will also periodically arrange for delivery of
additional ad hoc instruction and/or information to staff on risk assessment.
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8
MONITORING COMPLIANCE WITH THIS POLICY
The table below outlines the Trusts’ monitoring arrangements for this
policy/document. The Trust reserves the right to commission additional work or
change the monitoring arrangements to meet organisational needs.
Aspect of
compliance or
effectiveness
being
monitored
Monitoring
method
Individual
responsible
for the
monitoring
Frequency
of the
monitoring
activity
Group /
committee
which will
receive the
findings /
monitoring
report
Those
responsible for
Risk
Assessments
undertake their
duties in line
the policy
Annual review
and report of
completed risk
assessments
Safety, Risk
and Security
Manager
Annual
Governance
Quality & Risk
Committee
Performance
monitoring of
Trust Risk
Register
Safety, Risk
and Security
Manager
Each
meeting
Corporate Fire
Health Safety &
Security
Committee
Safety, Risk &
Security
Manager
Risk
assessments
for the
prevention and
management of
violence and
aggression are
undertaken in
accordance
with this policy.
Risk
assessments
are completed,
including those
which are
mandatory/
statutory
Review of
sample 15
risk
assessments
10 from
inpatient units,
5 from
community
teams
Safety, Risk
and Security
Manager
Twice per
year
Corporate Fire
Health Safety &
Security
Committee
Safety, Risk &
Security
Manager
Staff have
completed
training
associated with
this policy in
line with TNA
Group /
committee /
individual
responsible
for ensuring
that the
actions are
completed
Deputy
Director of
Operations
Review of
Safety, Risk
Twice per
Corporate Fire
Safety, Risk &
sample 25
and Security
year
Health Safety &
Security
risk
Manager
Security
Manager
assessments
Committee
10 from
inpatient units,
5 from
community
teams and 10
from
Administration/
Estates
services
Compliance with training will be monitored in accordance with the Learning and
Development Policy
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9
REFERENCES/ BIBLIOGRAPHY
HSE 2007, Management of Health and Safety at Work Regulations 1999, L21, HSE
Books, Sudbury, Suffolk,
HSE 2005, Control of substances hazardous to health regulations 2002: as
amended: approved code of practice and guidance, L5, HSE, London
HSE 2008, Health and safety, display screen equipment, regulations 1992 as
amended by Health and safety, miscellaneous amendments, regulations 2002, L28,
HSE, London
HSE 2009, How to tackle work-related stress, A guide for employers on making the
Management Standards work, INDG430, HSE, London
HSE 2003, Manual handling operations regulations 1992: as amended: guidance on
regulations, L23, HSE, London
NPSA, In-patient suicide using non-collapsible rails,
http://www.nrls.npsa.nhs.uk/resources/collections/never-events/core-list/noncollapsible-rails/
Statutory Instrument SI 2005/1541, Regulatory Reform Fire safety, Order 2005, The
Stationery Office, London, ISBN 0 11 0729945 5
NHS Security Management Service 2003, A Professional Approach to Managing
Security in the NHS, Counter Fraud & Security Management Service,
www.cfsms.nhs.uk
10 RELATED TRUST POLICY/PROCEDURES
The main reference documents referred to in this policy are:POL/0002/12 Risk and Safety Strategy & Policy
POL/002/19 Health and Safety Policy
POL/002/057 Policy for Lone Working
POL/002/039 Policy on Control of Substances Hazardous to Health (COSHH)
POL/002/021 Policy on Safe use of Display Screen Equipment
POL/002/030 Policy and Procedure for Manual Handling
POL/002/013 Policy on New & Expectant Mothers
POL/002/014 Policy on Young Persons in the Workplace
POL/002/022 Fire Safety Policy
POL/002/015 Security Policy
POL/004/024 Stress at Work Policy
POL/001/008 Prevention and Management of Violence and Aggression (PMVA)
POL/001/048 Slips, Trips and Falls Policy
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APPENDIX 1 - RISK ASSESSMENT PROCESS FLOWCHART
Each step in the risk assessment process is described below. Each step must be
documented on the risk assessment record.
Identify Hazards
Consider what work tasks that are undertaken by staff and the environments in
which those tasks are undertaken. Identify the activities, situations or environmental
factors that have the potential to cause harm. It is advisable to encourage
involvement from people undertaking potentially hazardous activities in the risk
assessment process (or their representatives) in order that the full range of risk
issues can be identified and workable control measures implemented
Identify People and/or Services at Risk
Consider which people and/or services may be effected by the identified hazard.
This could include staff, patients, visitors, carers, partner agencies etc. The ability, or
otherwise, of the Trust to deliver services to the standard or quality expected should
also be considered.
.
Consider the Potential Risks
Consider the potential effects the hazards may have on people, services, or property
should they actually materialise. For example, an insecure storage area may result in
theft of valuable materials which in turn will have a financial consequence for
replacing the item, but in the meantime services or tasks could be disrupted until the
equipment is replaced. The realistic foreseeable potential consequences of the
hazard should be documented on the risk assessment.
Identify Existing Control Measures
Consider what actions have already been taken to minimise the likelihood of a
hazard materialising, or to reduce the consequences should it occur. Control
measures can vary widely in nature (too wide to list within this document, but can
include measures such as provision of training, purchase and installation of
equipment, changing practices or processes, etc.).
At this stage the assessment needs to be given a risk grading.
Grade the Risk
Risk grading is determined by considering how likely people or services are to be
exposed to the identified hazard, and how severe the consequences would be
should exposure occur and/or the hazard materialise, taking into account what has
already been done to try to control exposure and/or consequences.
The Trust operates a 5 x 5 risk grading matrix, based on a 1-5 scale for likelihood
and consequence. Using this scale, risk scores can range from 1 to 25. Risks graded
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15 or above are considered High Risk and are eligible for consideration onto the
Corporate Risk Register. The matrix operates on the following descriptors:Quantify the potential for exposure to the hazard or the hazard materializing, based
on the definitions below:1
2
3
4
5
Rare
Unlikely
Possible
Likely
Almost Certain
May only occur in exceptional circumstances
May occur at some time
Will occur from time to time
Will occur at some time in the near future
Will occur at any time and reoccur frequently
Quantify the potential consequences, based on the definitions below:Injuries
Financial
Impact
Impact on Health
objectives
Compliance
Service
Delivery
1
Insignificant
No obvious
harm.
No injury
Costs £10k
and under.
No Significant
effect on quality of
care.
No effect on
compliance issues
No effect on
ability to deliver
services
2
Minor
No permanent
damage.
First Aid injury.
No lost time.
Sprain, strain,
burn. May
require medical
treatment.
Lost time.
Temporary
incapacity.
Loss of limb,
fracture,
crushing.
RIDDOR
reportable
incident.
Exposure to
Toxins.
Permanent
Incapacity.
Fatality.
Multiple
casualties.
Costs up to
£100k.
Noticeable effect
on quality of care
Ability to deliver
services may be
effected
Costs up to
£500k
Significant effect
on quality of care.
Compliance with
statutory/mandatory
requirements may
be effected
Compliance with
statutory/mandatory
requirements is
likely to be effected
Costs up to
£5m
Patient care
significantly
impaired.
Compliance with
statutory/mandatory
requirements
significantly
impaired
Ability to deliver
services is
significantly
impaired. Major
disruption to
service
Costs over
£5m.
Patient Care
impossible.
Failure to meet
statutory/mandatory
requirements
Unable to deliver
services
3
Moderate
4
Major
5
Catastrophic
Ability to deliver
services likely to
be effected
Calculate the risk grading
Multiply the ‘Likelihood’ figure and the ‘Consequences’ figure to calculate the Risk
Grading. For example, if the Likelihood was graded as 4 (likely) and the
Consequences were graded as 3 (moderate), the Risk Grading would be 4 x 3 = 12.
1.1.1.1.1.19 Likel
ihoo
d
This risk grading will equate to a low, medium, moderate, or very high risk, as can be
seen on the risk grading grid below.
Consequences
Policy for Service Delivery
Health & Safety Risk Assessment
Approved 15/04/2013
Page 15 of 21
Our Ref: POL/002/003
Likelihood
1 Insignificant
2 Minor
3 Moderate
4 Major
5 Catastrophic
5 Almost Certain
5
10
15
20
25
4 Likely
4
8
12
16
20
3 Possible
3
6
9
12
15
2 Unlikely
2
4
6
8
10
1 Rare
1
2
3
4
5
Red
Orange
Yellow
Green
15-25
8-12
4-6
1-3
Very high risk
Moderate risk
Low risk
Very low risk
1.1.1.1.1.20 Likel
ihoo
d
Further Actions to Reduce Risk (Risk Treatment Action Plan)
Next consider what, if anything, could realistically be done to reduce the risk further,
bearing in mind the reasonably practicable standard that must be met. Realistic and
proportionate target timescales should be set for future actions to be implemented.
The manager is responsible for leading on implementing the risk treatment action
plan, for seeking the necessary approvals / assistance where appropriate, and for
monitoring progress with those actions.
All further actions to reduce risk identified within risk assessments form part of an
organisation wide action plan to reduce and manage risks. Progress with identified
actions must be managed and monitored by local managers. Risk assessments must
be kept updated to reflect where actions have been undertaken/completed.
1.1.1.1.1.21 Likel
ihoo
d
Hierarchy of Risk Controls
Wherever reasonably practicable all risks will be combated at source.
Where hazards affect the workplace as a whole, or groups of people working within a
building or elsewhere, priority should be given to control measures that protect the
whole workplace or the group, rather than those that protect individuals. Where
individual controls are required they should be suitable to the meet the individual’s
needs. When deciding which preventative and protective control measures to
implement, the following hierarchy must apply wherever it is reasonably practicable
to do so.
•
•
•
•
•
Eliminate the risk by avoiding the hazard, i.e. do the job in another way but do not
introduce new hazards.
Substitute the hazard with something less hazardous, i.e. change a substance or
alter a process, a risk will still exist but will be reduced from what it was.
Use Engineering Controls to ‘design out’ the hazard, for example using new
technology in a building refurbishment or new build, or provision of new
equipment.
Use Administrative Controls to improve policies, procedures and systems of
work.
Supply Personal Protective Equipment to individuals. Provide appropriate
Instruction to staff
Policy for Service Delivery
Health & Safety Risk Assessment
Approved 15/04/2013
Page 16 of 21
Our Ref: POL/002/003
FLOWCHART OF RISK ASSESSMENT PROCESS & LINKS WITH RISK
REGISTERS
Consider work tasks undertaken by staff and
environments in which they are undertaken,
also consider services delivered and associated
compliance / quality standards
Identify hazards and risk management issues
associated with work tasks / environments /
services
Compile local risk register of all identified risks
Record a detailed risk assessment on the Ulysses
risk database for identified risk issues.
Identify ACTUAL practice in the control measures
section
state whether there are any gaps or weaknesses
in safety, service delivery or compliance
Grade the risk taking into account existing control
measures
Identify if any additional control measures are
possible / required and record on risk treatment
plan
Communicate findings of
risk assessments to
those exposed
Continue to implement existing control
measures, and monitor progress with risk
treatment plan seeking assistance / approvals
from management or specialist advisers where
necessary
Notify relevant Director
(through Locality Manager)
if risk is ‘significant’,
‘unacceptable’ or graded
15 or above.
Director to consider
escalation of risk to
Corporate Risk Register
Director
decision to
retain on
local risk
register
Review risk assessments
to reflect progress with risk
treatment plan
at least annually or earlier if
circumstances change that affect the
validity of assessment
Policy for Service Delivery
Health & Safety Risk Assessment
Approved 15/04/2013
Director
decision to
refer for
inclusion on
to Corporate
Risk Register
RMC decision
Refer back to
local risk
register
Page 17 of 21
Include on
Corporate Risk
Register
Our Ref: POL/002/003
APPENDIX 2 - LIGATURE POINT / STRANGULATION RISK ASSESSMENT
METHODOLOGY & PROTOCOL
In order to determine the priority in which ligature point minimisation work will be
undertaken and funded for non-mandatory ligature points, an assessment of the risk
posed by the ligature point in question must be undertaken. For the purposes of this
assessment, it is assumed that the consequence of a successful suicide attempt is a
fatality. It is also assumed that any fixtures and fittings designed to be anti-ligature in
nature do not present a risk and do not need to be specifically identified in these
assessments.
The methodology for this assessment is as follows:Each ward is to undertake an assessment of their ligature point risks.
1. A survey of the location and type of ligature point on each ward must be
undertaken.
2. The general propensity of patients on the ward towards suicidal tendencies
should be assessed (P), using the likelihood scale of 1 – 5, in accordance with
the Trust’s regular risk grading system as follows;
1.
2.
3.
4.
5.
Rare, may only occur in exceptional circumstances
Unlikely, may occur at some time
possible, will occur from time to time
likely, will occur at some time in the near future
almost certain, will occur at any time and reoccur frequently
3. On a room/area basis, the patients’ opportunity to gain access to any ligature
points contained within that room/area unsupervised and/or witnessed by staff
or others should be assessed (O), using the likelihood scale of 1 – 5, in
accordance with the following definitions.
1. No patient access, therefore no observation required, e.g. clinical
rooms.
2. Fully observed at all times, e.g. observation rooms.
3. Observed most of the time by staff and/or other patients, e.g. corridors.
4. Observed from time to time by staff and/or other patients, e.g. sitting
rooms.
5. Unobserved, e.g. bedrooms, toilets
4. For each room/area, multiply the propensity grading (P) by the opportunity
grading (O) to give a suicide risk for each room/area. (R). See grid overleaf.
5. Using the ‘Ligature Points - Likelihood of Use’ list (see page 3), multiply the
suicide risk for each room area (R) by the ‘likelihood of use’ (L) of that type of
ligature point to assess the risk grading for each ligature point identified on the
ward survey.
Policy for Service Delivery
Health & Safety Risk Assessment
Approved 15/04/2013
Page 18 of 21
Our Ref: POL/002/003
6. Using this methodology, the risk grading for ligature points will range from 1
through to 100; with 50+ = high risk, 25-49 = moderate, 15-24 = low, 1-14 =
very low. See grid overleaf.
7. For risk register purposes divide the final score by 4 to give a grading that falls
in line with Trust policy for inclusion on the Register.
Working out the suicide risk for each room/area
Propensity (P)
Opportunity (O)
1
2
3
4
5
5
5
10
15
20
25
4
4
8
12
16
20
3
3
6
9
12
15
2
2
4
6
8
10
1
1
2
3
4
5
PxO=R
Suicide risk for room/area (R)
Working out the risk grading for each ligature point
Likelihood of Use (L)
1
2
3
4
25 25 50 75 100
20 20 40 60 80
16 16 32 48 64
15 15 30 45 60
12 12 24 36 48
10 10 20 30 40
9
9
18 27 36
8
8
16 24 32
6
6
12 18 24
5
5
10 15 20
4
4
8
12 16
3
3
6
9
12
2
2
4
6
8
1
1
2
3
4
Policy for Service Delivery
Health & Safety Risk Assessment
Approved 15/04/2013
Page 19 of 21
Our Ref: POL/002/003
Ligature Points - Likelihood of Use
NB: the schedule below is subject to review and change without further amendment
to this policy.
It is assumed that any fixtures and fittings designed to be anti-ligature in nature do
not present a risk and do not need to be specifically identified in these assessments.
LIGATURE POINT
coat hooks
Beds of ‘open frame’ design
Beds with high bed head (frame)
Cable trunking pipes with brackets
cubicle partitions – fixed
cubicle rails – fixed
Curtains – on anti-lig rail
Curtains – on fixed rail
door closers - external
door closers – internal
door handles
door hold open devices
Doors – flush into frame
Doors – gap at top of door
Drain pipes
Drainage grills (shower/bathroom)
exposed pipes and brackets
Fire alarm manual call point
Fire alarm sounders
Furniture (chairs / tables)
Furniture (heavy) with legs / supports
grab rails (in toilets/bathrooms)
Handrails
likelihood
of use
2
3
2
2
2
4
1
3
2
3
2
2
3
2
3
2
3
1
2
1
2
3
2
LIGATURE POINT
light & nurse call pull cords - flexible
light & nurse call pull cords - rigid
light fittings – dropped from ceiling
Light fittings – fixed/flush to ceiling
Light switch fittings
loose furniture
radiator covers
shelf fittings / brackets
shower fittings
shower rails – fixed
Soap dispenser – non anti-lig type
suspended ceilings – fixed tiles+
suspended ceilings – unfixed tiles
Toilet base – free-standing pan
towel dispensers
towel rails
ventilation grilles
Wardrobe / cupboard doors
wardrobe coat-hanger rails
wash basin taps and brackets
Water fountain
window curtain rails - fixed
Window seals (rubber strips)
Windows (openable)
likelihood
of use
Key:
MANDATORY instruction to control/remove
4
Likely to be used / frequently used as method* 3
Known to be used / possible to use as method 2
Not known to be used, but use may be possible1
*according to available statistics
+mandatory instruction to assess risk – assessed by Estates as less likely to be used
than unfixed tiles
Policy for Service Delivery
Health & Safety Risk Assessment
Approved 15/04/2013
Page 20 of 21
Our Ref: POL/002/003
3
1
2
1
1
1
2
2
3
4
2
3
4
1
2
3
2
3
3
2
2
4
4
3
APPENDIX 3 - STATUTORY/MANDATORY RISK ASSESSMENTS
Administration/ security of drugs and medicines
Bed rails
Car park safety and security
Driving on Trust business
Falls from height
First aid
Ligature points/ strangulation risks (inpatient areas)
Lone working
Medical Gases
Manual handling
Physical security of premises/ workplaces
Security of personal items – patients
Security of personal items – staff
Security of Trust assets
Security preparedness and resilience
Slips, trips and falls (both staff and patients)
Stress
Use of display screen equipment
Violence and aggression
Wandering patients
Work with sharps and needles
Young workers
Policy for Service Delivery
Health & Safety Risk Assessment
Approved 15/04/2013
Page 21 of 21
Our Ref: POL/002/003