Conducting a Risk Assessment Procedure

Version: 2.2, v1 approved by MT Jan 09

Bodies consulted: -
Approved by: PASC
Date Approved: 24.4.15
Lead Manager: Health and Safety Manager
Responsible Director: Director of Corporate Governance and
Facilities
Date issued: Mar 15
Review date: Feb 2018

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Conducting a Risk Assessment Procedure, v2.2, Mar 15 Page 1 of 21

 Contents

1 Introduction ............................................................................. 3
2 Purpose ..................................................................................... 3
3 Scope ........................................................................................ 4
4 Definitions ................................................................................ 4
5 Duties and responsibilities ...................................................... 5
6 Procedures ................................................................................ 6
7 Training Requirements .......................................................... 10
8 Process for monitoring compliance with this Procedure .... 11
9 References .............................................................................. 11
10 Associated documents ........................................................ 12

Conducting a Risk Assessment Procedure, v2.2, Mar 15 Page 2 of 21

 Conducting a Risk Assessment Procedure

1 Introduction

Risk assessment is a technique for proactively identifying and addressing risks in all
settings. It is a key tool for effective risk management both in the context of health
and safety management and for management of risks in all other settings across the
Trust (including clinical risks, financial risks, environmental risk etc). The Trust has a
legal duty to undertake risk assessments to protect staff under the Health and Safety
at Work Act; in addition, it is key building block of the Trust’s approach to governance
and risk management.

Whilst recognising that risk can never be eliminated, effective channelling of resources
to identifying and reducing risk is sound business and healthcare practice, and offers
protection to patients’ staff and assets of the Trust. The objective of risk assessment is
to reduce and/or eliminate the consequence of a risk being realised thereby reducing
accidents, harm, loss or disruption to services.

Effective risk assessment is based on a series of steps, involving identifying risks,

assessing the extent of the risk, determining whether action needs to be taken to
reduce the risk, and then taking action and evaluating the results of the action. This
document describes these steps in some detail, but is not designed to be prescriptive,
as different types of risks and different settings will require local adaptation of the
principles.

The document contains details of a generic risk assessment recording form which can
be used in many settings.

Advice and support on the use of this procedure can be sought from the Health and
Safety Advisor and the Governance and Risk Lead

2 Purpose

The purpose of this procedure is

 To ensure that a consistent approach to the application of risk assessment

techniques is applied across all services within the Trust.

 To create and maintain a culture of risk awareness within the Trust, which is
reflected in both business planning and operational management.

 To promote a risk aware organisation through risk assessment and proactive risk
management across all services.

 To set out training and support available for staff who undertake risk assessments.

Conducting a Risk Assessment Procedure, v2.2, Mar 15 Page 3 of 21

3 Scope

The principles contained in this procedure are applicable to the assessment of risk in
all settings across the Trust, and are consistent with the Risk Strategy and Policy
adopted by the Trust.

The risk matrix tool (Appendix A) is relevant to the rating of the extent of a risk in all
settings and has been designed to promote consistency in risk assessment and risk
evaluation to allow the ranking of risks (for example on the risk register), to support
decisions as to resource allocation, to address identified risks.

A risk assessment pro forma (Appendix B) has been designed primarily for use for
health and safety risk assessment across the Trust. However, it can be used in other
risk settings to support a systematic approach to conducting an assessment, or can be
adapted for local use.

Other risk assessment tools (Appendix C and D) are relevant in different settings in the
Trust.

4 Definitions

The following definitions are used throughout this procedure.

Hazard A hazard is something which has the potential to cause injury,

illness, harm, loss or damage.

Risk the combination of the likelihood and consequence of the hazard

being realised

Consequence The potential consequence (or severity) of the risk being realised
(it is described in terms of levels of harm and/or loss)

Likelihood How often the risk event might happen (e.g. per
procedure/episode or within a specified timeframe).

Risk Rating A measurement of the risk useful for assessing the priority for
control measures for the treatment of different risks. The risk
rating is derived from the ‘risk score’ for consequence x ‘risk score
for likelihood (see Risk Matrix at Appendix 1) *

Risk The process by which the risk is managed to reduce the

reduction consequence and/or likelihood of the occurrence of the event.

Conducting a Risk Assessment Procedure, v2.2, Mar 15 Page 4 of 21

5 Duties and responsibilities

5.1 The Chief Executive

The Chief Executive has overall responsibility for risk management at the Trust. He has
delegated delivery responsibility within the management structure to:

 The Medical Director for clinical risk

 The Director of Corporate Governance and Facilities for operational risk
 The Director of Finance for strategic risk
 All directors for risks in their directorate
 The Senior Information Risk Owner for all information risks

5.2 All managers

Managers working throughout the Trust are responsible for ensuring that local risk
management activities including risk assessments are carried out to support Trust-wide
learning from risk issues.

5.3 Health and Safety Manager

In respect of risk assessment the Health and Safety Manager is responsible

for:

 Fulfilling the requirements of Health and Safety Advisor to the Trust

 Promoting the use and understanding of risk assessment and audit processes
throughout the Trust
 Arranging, in conjunction with the Governance and Risk Adviser, the delivery of
training on risk assessment as determined by the training needs analysis
 Coordinating annual risk assessments of estates and facilities managed by the Trust
 Managing the strategic and operational risk registers
 providing regular reports to the work streams reporting to the Clinical Quality
Safety and Governance Committee (CQSG) as required.

5.4 Governance and Risk Adviser

Is responsible for providing expert advice and support on risk management, and for
providing training for all levels of staff on risk assessment, risk management and risk
processes.

The Governance and Risk Adviser provide regular reports to the work streams
reporting to the Clinical Quality Safety and Governance Committee (CQSG) as
required.

Conducting a Risk Assessment Procedure, v2.2, Mar 15 Page 5 of 21

 5.5 Information Governance Manager

Is responsible for ensuring the effective management of data as a way of protecting

information assets managed by the Trust and for facilitating an annual programme of
risk assessments of information governance assets to be undertaken by information
asset owners.

5.6 All staff

All staff have individual responsibility for engaging in risk management activities at
the Trust. Key responsibilities of staff in respect of risk assessment are to:
 Bring immediate /hazard issues to the attention of their line manager.
 Act safely at all times.
 Co-operate with risk assessments and action plans in operation to reduce risk.
 Comply with the Trust’s policies, procedures and guidelines that are in place to
protect the health, safety and welfare of anyone affected by the Trust’s activities.

6 Procedures

The Trust follows the risk assessment process described by the National Patient Safety
Agency. The process involves 5 steps as shown below:

Figure 1: Five steps to risk assessment (source: National Patient Safety Agency (NPSA))

Conducting a Risk Assessment Procedure, v2.2, Mar 15 Page 6 of 21

 6.1 Identify the hazards (what can go wrong?)
To prevent harm it is important to understand not only what is likely to go wrong but
also how and why it may go wrong. Consider the activity within the context of the
physical environment, and the culture of the organisation and the staff who perform
the activity.

Decide who might be harmed or what the impact will be on the organisation (assets,
environment and reputation) and how. Take into account things that have gone
wrong in the past and near-miss incidents. Learn from the past:

 Walk around the workplace and talk to staff.

 Map or describe the activity to be assessed.

 The risk assessment may require a multi-disciplinary team to ensure that all areas
of the activity or task to be assessed are considered.

6.2 Decide who might be harmed or the effect on the organisation and how (what can go
wrong? who is exposed to the hazard?)
People will make mistakes. It is necessary to anticipate some degree of human error
and try to prevent the error from resulting in harm.

 Consider the number of staff members or patients that might be affected over a
stated period of time. When quoting the number of patients affected you
should always state the length of the assessment period.

 Think about the complexity of the task.

6.3 Evaluate the risks (how bad? how often?) and decide on the precautions (is there a
need for further action?)
Consider both the consequence (how bad?) and likelihood (how often?). Is there a
need for additional action? The law requires everyone providing a service to do
everything reasonably practical to protect patients and staff from harm.

 Identify the current controls/precautions that are in place to prevent the risk
form causing harm or loss.

 Use the Risk Matrix Tool (appendix 1) and guidance in the Risk Assessment pro
forma (appendix 2) to grade the risk.

 Decide whether further precautions need to be taken to reduce the risk and if
action is required, determine what changes need to be made.

 Re-evaluate the risks assuming the precautions (controls) have been taken (to
check the expected impact of the proposed changes).

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6.4 Record your findings, proposed action and identify who will lead on what action.
Record the date of implementation.
6.4.1 Documentation
It is a key part of this procedure that risk assessments must be recorded,

The Trust has developed a range of to support this

 Appendix B ‘SWIFT’ a structured what if

 Appendix C environmental risk (to be completed/updated at least annually for
each site

The record serves as evidence that the risk has been identified and evaluated and
provides the information necessary to review progress accurately over time to see if
the risk has been reduced.

Risk assessments and action planning should be reviewed and changed when
necessary. This is easy only if the assessment is well recorded and the logic behind the
decisions transparent. Your documentation should show the following:

 That a thorough check was made to identify all the hazards and treat all the
significant risks;

 The precautions that are in place are appropriate to the risk and remain effective
;

 The solutions proposed or being actioned to reduce the risk are realistic,
sustainable and effective.

6.4.2 Storing Completed Assessments

Divisions and departments should make local arrangements for the storage of
completed risk assessments. A copy of the completed form can be sent to the Health
and Safety Manager who will store it on the risk server but it remains the responsibility
of the local manager to ensure that a copy is kept locally.

If the electronic risk assessment form is used then it can be uploaded on to the
electronic data base operated by the Health and Safety Manager. This provides a
storage facility and the ability for other staff to review completed assessments which
can facilitate local planning for risk reduction.

Copies of completed risk assessments can be sent to the Health and Safety manager for
filing; however, it is the responsibility of the local manager to maintain copies

Clinical risk assessments relating to an individual patient should be stored in the

patient’s medical records.

6.5 Review and update the assessment as necessary

Risk assessments should be reviewed in the following circumstances:

 When a change is planned that could have an impact on the risk.

Conducting a Risk Assessment Procedure, v2.2, Mar 15 Page 8 of 21

  If the proposed action generates a new hazard;

 When there has been a significant change.

 Following the completion of an action plan designed to reduce the risk (to
confirm that risk reduction has been achieved)

 Routinely at least on an annual basis; (more frequently for high risks)

6.6 Management of Risk Assessment

6.6.1 Line managers are responsible for ensuring risk assessments are undertaken in their
areas. The Health and Safety Manager will support the line managers and provide
training as appropriate.

6.6.2 The management of risks identified through the risk assessment process will be
determined by the risk rating, (appendix 1) see below:

The amount of effort/resources that are to be committed to an identified risk is

determined by the risk score. The Trust has a scheme of escalation (shown at Figure
3).

 Risks scored 1-5: are considered low risk and therefore are tolerated by the Trust

 Risks scoring 6-8: are considered moderate risks and should be managed /treated
so that they are made as ‘low as reasonably practicable’. These risks will usually be
managed locally unless they are Trust wide when the appropriate corporate
department will lead on management.

 Risks scoring 9-12 are considered high risks. These risks must be treated, i.e. an
action plan should be developed and implemented that seek to reduce the
potential impact of the risk (i.e. reduces the risk score). These risks will be added
to the risk register and will be reviewed by the Management Committee and
overseen by the Clinical Quality, Safety, and Governance Committee High risks
scoring 12 will also be reviewed by the Board.

 Risks scoring 15-25 are considered as extreme/catastrophic risks. These risks must
be treated, i.e. an action plan should be developed and implemented that seek to
reduce the potential impact of the risk (i.e. reduces the risk score). These risks will
be added to the risk register and will be reviewed by the
 Management Committee and the Clinical Quality, Safety, and Governance
Committee High risks scoring 12 will also be reviewed by the Board.

Risk treatment plans have to be developed according to the level of risk and the needs
of the organisation. In broad terms the Trust will seek to tolerate risks (1-5), and treat
risks with a score of 6 or more, and where appropriate will seek to transfer risk to
another provider, or may consider the need to terminate the risk by terminating the
aspect of service affected if no other solution can be identified, and the risk is extreme
(i.e. 15+).

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 Risks scored 6-8 will be treated so that they are as low as reasonably practicable, and
then tolerated.

Note: the level of management action is for guidance only. Where management
action is insufficient to reduce the risk rating this should be escalated via the
line management structure.

Escalation levels are shown below.

Escalation level
Risk level Risk score
Extreme
15-25 Board of Directors
Red
High Management committee
9-12
Orange (reporting to Board )
Moderate
6-8 Directorate/Team
Yellow
Low
Team but monitored at
Green 1-5
Directorate level
(tolerated risks)

Figure 3 Escalation levels

6.6.3 All risks assessments must be reviewed when a major change occurs that could have an
impact on a risk.

6.6.4 Directors are responsible for adding significant risk s to the trust risk register.

6.6.5 The Clinical Quality Safety and Governance Committee (CQSG) oversees the risk
register, supporting Directors in the assessment and management of their risks.

6.6.6 The Board of Directors will receive the risk register (for risks 9+) for information and
review on a quarterly basis the risks graded 12+ (both strategic and operational) on a
two monthly basis.

7 Training Requirements
The Trust has conducted a training needs analysis and will make the following
provisions for training

All staff joining the Trust will be briefed on the principles of risk management including
risk assessments as part of the Trust’s induction programme.

Specific risk assessment sessions will be held for Directors and Managers, either in
groups or as one to one training delivered by Risk experts in the Trust and/or external
trainers as appropriate. The 2 yearly mandatory INSET sessions for all staff will include
promotion of risk assessment techniques and this procedure.

Conducting a Risk Assessment Procedure, v2.2, Mar 15 Page 10 of 21

8 Process for monitoring compliance with this Procedure

This procedure will be monitored in a number of different ways including:

Locally, line managers are responsible for reviewing their risk assessments at regular
intervals. The schedule for the review of the risks assessments will be determined by
the residual risk rating and/or the timescales indicated in the action plan.

The work streams reporting to CQSG will consider risks relating to their areas of
responsibility and will ensure that appropriate action plans are implemented and
monitored, escalating any risks that are not effectively addressed to the Management
Team and CQSG and via monitoring of the risk register.

The CQSG will review the risk related assurance and any risks escalated for
consideration and advice on the robustness of action plans to reduce risk.

9 References

Health and Safety Regulation

The Management of Health and Safety at Work Regulations 1992
(amended in 1999);
The Manual Handling Operations Regulations 1992;
Health and Safety (Display Screen Equipment) Regulations 1992;
The Personal Protective Equipment at Work Regulations 1992;
The Provision and Use of Work Equipment Regulations 1998
The Workplace (Health, Safety and Welfare) Regulations 1992.

Regulations requiring risk assessments to be carried out

Control of Substances Hazardous to Health Regulations 1998 (amended in 1999);
Noise at work Regulations 1989;
Control of Lead at Work regulations 1980 and 1998;
Control of Asbestos at Work Regulations 1987;

Note this is not an exhaustive list.

Additional sources of information

Healthcare risk assessment made easy, NPSA, March 2007
http://npsa.nhs.uk/patientsafety/improvingpatientsafety/patient-safety-tools-and-
guidance/risk-assessment-guides/

Health and Safety in Health and Social Care Services (HSE website)
http://www.hse.gov.uk/healthservices/index.htm

A risk matrix for risk managers, NPSA, January 2008

http://npsa.nhs.uk/patientsafety/improvingpatientsafety/patient-safety-tools-and-
guidance/risk-assessment-guides/risk-matrix-for-risk-managers/

Conducting a Risk Assessment Procedure, v2.2, Mar 15 Page 11 of 21

10 Associated documents1

Appendix A
RISK SCORE MATRIX DEFINITIONS

RISK SCORE = Consequence grade x likelihood score

Descriptor CONSEQUENCE/IMPACT DESCRIPTION

/ Grade

Negligible impact on strategic objectives

Negligible
Nil/negligible:
Injury, loss, service interruption, environmental/estate impact, impact on reputation impact on
(1) quality. litigation or complaint

Small variance from overall strategic objective

First aid treatment with full recovery
Complaint possible
Low Local low key external interest

(2) Minor:
financial loss (up to 5K),service interruption ,environmental/estate impact, impact on
reputation, impact on quality

Notable variance from overall strategic objective

Medical treatment required up to 3 months to recover
Reportable under RIDDOR
Moderate Complaint probable

(3) Moderate :
financial loss (5K – 200K), service interruption for more than one week, environmental/estate
impact, Impact on reputation. Local press, stakeholders express concern, impact on quality
moderate loss of information (recoverable) ,moderate risk of low value claim

Significant variance from overall strategic objective

Long term illness or injury ( up to one year)
Reportable under RIDDOR
Complaint expected/received
Major
Major :
(4) financial loss (200K – 3M) , service interruption of more than one month, environmental/estate
impact leading to loss of service, significant impact on reputation, significant medial interest
more than one week, significant concerns raised by stake holders , significant impact on
quality including risk of failing to achieve ‘excellent’ in annual health check in one or more
standards, major loss of information (recoverable) , high value claim or action by HSE
anticipated, moderate risk of low value claim

Failure to meet strategic objective threatens independent functioning or stability of the Trust.

Extreme/ Death, Financial loss3M+, Certain risk to reputation, national press3+ days, of C questions
Catastrophic Serious/long term and/or permanent loss of information that impacts directly on service
delivery, Quality- External controls exerted , Threat of Judicial review, expected litigation
valued at 1M+,High profile breach of confidential information (eg patient identity)
(5)
Buildings/property condemned leading to major loss of service

1
For the current version of Trust procedures, please refer to the intranet.

Conducting a Risk Assessment Procedure, v2.2, Mar 15 Page 12 of 21

 Score Descriptor LIKELIHOOD OF REPEAT EVENT DESCRIPTION

Very unlikely to
1 Will only occur in exceptional circumstances.
occur

2 Unlikely to occur Unlikely to occur but the potential exists

3 Could occur Reasonable chance of occurring – has happened before on occasions

4 Likely to occur Likely to occur – strong possibility.

Almost certain to
5 The event is expected to occur in most circumstances.
occur

RISK SCORE MATRIX

Almost certain to occur 5 5 10 15 20 25

Likely to occur 4 4 8 12 16 20
Likelihood

Could occur 3 3 6 9 12 15

Unlikely to occur 2 2 4 6 8 10

Very unlikely to occur 1 1 2 3 4 5

1 2 3 4 5
Catastrophic
Risk Matrix Negligible Minor Moderate Major
/ Fatal
Consequence

Conducting a Risk Assessment Procedure, v2.2, Mar 15 Page 13 of 21

 Escalation of Risk is determined by risk score

Escalation level
Risk level Risk score
Extreme Board of Directors
15- 25
Red
High Management committee
9-12
Orange (reporting to Board )
Moderate Directorate/Department
6-8
Yellow
Low Department
Green 1-5 but monitored at
(tolerated risks) Directorate level

Response to Risk the 4 T’s

Tolerate Accept the risk. I.e. do nothing.

Treat Continue the activity but actively work on mitigating the risk
Transfer Move the risk for example, outsource to another organization.
Terminate Stop the activity, as it is too risky to do anything else.

Closing risks: When the risk has been treated, transferred or terminated and is no longer
considered to be a risk to the Trust the risk is ‘closed’.

Tolerated risks remain on the risk register and should be reviewed periodically at Committee
level and escalated as appropriate

Conducting a Risk Assessment Procedure, v2.2, Mar 15 Page 14 of 21

1. Appendix B
2. Structured What If Risk Assessment Technique (SWIFT)
The SWIFT log sheet provides the structure for the discussion of each hazard, and its format should be decided in
advance of the meeting. For this exercise the log sheet includes:
 Situation that could create a risk (Hazard) Hazard definition - a brief description of what is meant by the hazard, ie
the ‘what if question’
 Causes - usually a few illustrative ones, since a group is not efficient at defining an exhaustive list. These may be
cross-referenced to other hazards. As an option, causes may be omitted for brevity.
 Consequences - the main types of harm that may result if the hazardous event occurs. It is important to discuss the
potential consequences, and not to dismiss them on grounds such as low probability.
 Safeguards - the existing measures in place to prevent the hazardous event occurring or mitigate its effect.
 Current Risk: the risk level as determined from the estimated likelihood and severity using the risk matrix.
 Recommendations - a consensus view from the group on the need for further safeguards if the existing ones appear
inadequate, or the need for further study.
 Future Risk: the risk level determined as for the Current Risk, but assuming that the recommendation has been
implemented.

Suggested SWIFT category prompts to help team to ‘cover all bases’

3. Man - human error eg failure to respond to a brick appropriately
4. Machine – eg IT, Equipment, instrumentation failure
5. Tests – eg analytical or test errors and problems,
6. Emergency situations – eg loss of utilities
7. External Effects or influence – eg media interest
8. Environmental – eg effect of surroundings on wall guides
9. When calculating risk value consider the consequence first and then the likelihood for ‘that consequence/set of
consequences Risk Score = consequence x likelihood
10.

SWIFT Risk Assessment Pro forma Date:

Section / Task:

Description of Section or Task to be analysed Risk Assessment team:

What if question Causes Consequences Safeguards Current Risk Recommendations Future Risk*
/Additional
C L R safeguards C L R

* This is the anticipated risk level after the recommendations/actions have been applied.
 Appendix C
ESTATES AND FACILITIES ENVIRONMENT RISK ASSESSMENT

SITE: ASSESSOR:

ASSESSMENT DATE: : ACTION DUE DATE: REVIEW DATE

Risk Assessment Process:

Stage 1: Check the list of potential workplace HAZARDS and tick which apply to the area being reviewed
describe the existing control measures and use the risk matrix to estimate the level of RISK.
Further rows can be added for other hazards that are not listed Assess these risks for the site/
area being reviewed. *The risks below should be assessed ‘generically’ i.e. Recognising that any
of the hazards if not properly managed could cause harm to staff, patients, visitors or contracts

Stage 2 Develop action plan for all risks 9+ (see below)

Stage 3 Add all risks 6+ to trust operational risk register (estates and facilities page)

Stage 4 Review this risk assessment at least annually and at other times if there are changes in
circumstances that could impact on the risk
 ENVIRONMENTAL RISK ASSESSMENT TEMPLATE

Hazard: Does Existing Control Measures: Risk

Conseque

Likelihoo
this Rating:

nce
(Has the potential to cause harm, apply? (examples listed add details of specific arrangements that apply to

d
damage or loss) * site/location being assessed) (C x L)

Intruder access outside work hours Lock down scheduled

Ability to ‘lock down’ site or sections

of the site in response to emergency

Loss of Trust property through theft

Loss of loss of Trust property through

damage / inappropriate use

Slip, trip or fall of person on the same Access routes kept clear, surfaces maintained in good repair, use of
level – Risk of personal injury appropriate warning signs.

Working at heights 9incl with ladders)

Risk of personal injury

Manual handling of inanimate objects Health and Safety Policy, training for staff required to lift in course of
– Risk of personal injury/ill health, their employment
non-compliance with H&S Legislation

Use of mechanical equipment

including lifting equipment – Risk of Equipment assessed as ‘Fit for purpose’, safe use training and planned
personal injury, non-compliance with preventative maintenance programmes (PPM) to include Lifting
H&S legislation operations and Lifting Equipment Regulations 1998. (LOLER) Equipment
location monitored via inventory (no lending)
 Hazard: Does Existing Control Measures: Risk

Conseque

Likelihoo
this Rating:

nce
(Has the potential to cause harm, apply? (examples listed add details of specific arrangements that apply to

d
damage or loss) * site/location being assessed) (C x L)

`Use of electrical equipment - Risk of

personal injury, non-compliance with Regular electrical checks, (PAT testing).
H&S legislation

Fire – Risk of personal injury, damage

Fire Policy, fire risk assessments, fire prevention techniques, training and
to property and non-compliance with
fire drills to assess effectiveness of evacuation procedures.
H&S legislation

Exposure to/contact with hazardous

chemicals Risk of personal injury/ill COSHH training for all staff handling chemicals, avoidance of chemical s
health, non-compliance with H&S for cleaning etc
legislation

Violence and Aggression Procedure, training, incident reporting and

Exposure to violence or aggression – review
Risk of personal injury/ill health

Exposure to needles or risk of biting Infection Control Policy, access to expert advice via RFH, sharps boxes
injury due to work undertaken available on request
personal injury/ill health

Exposure to waste materials - Risk of Waste Management Policy, training, appropriate storage facilities and
personal injury/ill health provision and use of PPE.
Consider: Asbestos ; Food waste;
Other hazardous waste if relevant

Inadequate maintenance - Sufficient resources and effective PPM programmes.

Organisational risk which could impact
on patient treatment/care and affect
staff safety, non-compliance with H&S
legislation
ACTION PLAN

Note: An action plan must be completed for all risks scoring 9+ above, and may be completed for risks
scoring 6-8 if actions to reduce risk have been identified via assessment process. All risks scoring 6+ must be
added to the Trusts corporate risk register and the Corporate Governance Facilities Working Group will
monitor compliance with the action plan

Proposed Actions: By Whom: Target date Completion date

Stage 3: The risk assessment record must be REVIEWED every 12 months as a minimum to ensure that the
hazards are still current and the control measures remain effective. They should also be
reviewed upon any significant changes to the working environment or working practice and
following any serious accident or incident. The Risk Assessment Record should be held locally for
information purposes. All significant risk issues must be communicated to the appropriate
Director/Senior Manager for monitoring purposes and inclusion on the risk register. All staff
that may be ‘at risk’ must be informed of the significant hazards and any control measures they
may need to implement as part of their work activity e.g. the wearing of PPE etc.

Date of Review: ……………………….…….… By Whom:

…………………………..………….

Were changes made to the assessment at the review? Yes/No

Appendix D

Equality Impact Assessment (EQIA)

Form one – initial screening

1. Name of policy, function, or service development being assessed:

Risk Assessment Procedure

2. Name of person carrying out the assessment:

Jane Chapman Governance and Risk Lead

3. Please describe the purpose of the policy, function or service development:

This sets out the trusts approach to risk assessment across all areas of the trust

4. Does this policy, function or service development affect patients, staff and/or the
public?
Response: Yes
This is a procedural v document that sets out systems and processes to be applied when
risk assessing. It has no direct impact on equalities issues.

5. Is there reason to believe that the policy, function or service development could have
an adverse impact on a particular group or groups?
Response : NO

7. Based on the initial screening process, now rate the level of impact on equality groups
of the policy, function or service development:

Negative / Adverse impact:

Low…….
(i.e. minimal risk of having, or does not have negative impact on equality)
Positive impact:

Response: LOW NEGATIVE

Date completed …………………8.1.09 … ……………..

Print name ………………E Jane Chapman