RISK MANAGEMENT PLAN FOR

Transcription

1 RISK MANAGEMENT PLAN FOR AGED AND COMMUNITY CARE Aged and Community Services of NSW and ACT (ACS) have identified a need to support members in strengthening risk management in the Aged and Community Care sector. In response, ACS Consultancy offer services to members in developing and implementing risk management policies and processes. The attached tool is a sample template that is used during consultation with an organisation to create an organisational risk management plan. Gow-Gates also offer an obligation free insurance program audit and gap analysis to all ACS members. Whilst risk management is recognised as an essential component of good corporate governance, a number of recent changes in the industry have highlighted the need to ensure risk management is part of an organisation s culture, its philosophy, practices and business processes. These include: The introduction of the Community Care Common Standards and expected outcome 1.6 Management Australian Charities and Not for Profits Commission requirement for a risk management plan (planned implementation July 2014) Increasing focus on disaster management and emergency response A requirement for overnight respite services (NRCP) to develop and implement a risk management plan management may be defined as the process of identifying, assessing and judging risks, assigning ownership, taking actions to mitigate or anticipate them, and monitoring and reviewing progress. The Australian Standard defines risk as the chance of something happening that will have an impact on [an organisation s] objectives. It is measured in terms of consequences [the outcome] and likelihood [the rate of occurrence] and if the risk will have a positive or negative impact. A risk rating scale is used to identify risk management priorities. Likelihood The likelihood is related to the potential for risk events to arise. Rating A B C D E Likelihood Almost certain: will probably occur, could occur several times per year Likely: high probability, likely to arise once per year Possible: reasonable likelihood that it may arise over a five-year period Unlikely: plausible, could occur over a five to ten year period Rare: very unlikely but not impossible, unlikely over a ten year period Produced by Aged and Community Services Assoc of NSW & ACT : Nov 2012 Page 1 of 22

2 Consequence The consequence rating is based on the impact or degree of loss or damage. Rating Potential impact 1 Catastrophic: most objectives may not be achieved, or several severely affected 2 Major: most objectives threatened or one severely affected 3 Moderate: some objectives affected, considerable effort to rectify 4 Minor: easily remedied, with some effort the objectives can be achieved 5 Negligible: very small impact, rectified by normal processes priority The risk priority scale determines the nature of the risk and the action required. IMPACT A B C D E 1 Extreme (1) Extreme (1) Major (2) Major (2) Medium (3) 2 Extreme (1) Extreme (1) Major (2) Medium (3) Minor (4) 3 Extreme (1) Major (2) Major (2) Medium (3) Minor (4) 4 Major (2) Major (2) Medium (3) Minor (4) Minor (4) 5 Medium (3) Medium (3) Minor (4) Minor (4) Minor (4) Key 1 Extreme risks that are likely to arise and have potentially serious consequences requiring urgent attention 2 Major risks that are likely to arise and have potentially serious consequences requiring urgent attention or investigation 3 Medium risks that are likely to arise or have serious consequences requiring attention 4 Minor risks and low consequences that may be managed by routine procedures (Reference: NSW Department of Ageing, Disability and Home Care. It s Your Business Chapter 6: Management and Australian Standard AS/NZS 4360:2004 Management) For further information or support in developing a risk management plan please contact ACS Consultancy, on or for further information for an obligation free insurance program audit contact Gow-Gates on Produced by Aged and Community Services Assoc of NSW & ACT : Nov 2012 Page 2 of 22

3 Management Plan RISK MANAGEMENT PLAN FOR AGED AND COMMUNITY CARE Date Current to Reduce, Mitigate or Transfer ORGANISATION RISKS Financial: Failure of financial performance Failure to meet budget Organisation not financially sustainability Poor management of revenue & expenses and budget process Failure to remain solvent Inaccurate ACFI claiming Budget process Financial reporting Monitoring financial performance monthly by Board / Senior Management Review actuals vs budget, discussion of variances and strategies to meet shortfalls Strategic Plan Training Financial: Loss of income from investments Volatility in investment markets Conservative investment strategy Liquidity management strategy Financial: Theft, Fraud, Embezzleme nt of funds Financial security at risk Board and management reports Annual external audit of funds Recruitment process including mandatory police checks Financial delegation and approval process Policies and procedures, Code of Conduct Produced by Aged and Community Services Assoc of NSW & ACT : Nov 2012 Page 3 of 22

4 Current to Reduce, Mitigate or Transfer Financial: Poor cash flow management Poor budget / management of cash flow Inability to pay debts on time Poor credit rating Inability to pay salary & entitlements Monthly monitoring of cash flow Management approval of payment of creditors Liquidity management strategy Financial: Loss of business / Competition Lower occupancy, decreased referrals, decreased waiting list, unfilled packages. Poor community reputation Quality Management System Evaluate effectiveness of programs / responsiveness Strategic Plan Community needs analysis and Service Planning Marketing Interagency networks Financial: Failure to grow services / change in market conditions Impact on financial sustainability Inability to respond to community need Strategic Plan Board and Management monitoring of Strategic Plan Community needs analysis and Service Planning Interagency networks Produced by Aged and Community Services Assoc of NSW & ACT : Nov 2012 Page 4 of 22

5 Current to Reduce, Mitigate or Transfer Legal & Regulatory Compliance: Prudential arrangement s Non Compliance with Prudential Arrangements Potential cost implications Department of Health action Impact on reputation Board Governance Board training Policies and procedures Bond register Board reports Board compliance register Management Legal & Regulatory Compliance: Standards Non Compliance with Community Care Common Standards / Aged Care Accreditation Standards. Breach of Aged Care Act Department of Health Action Potential cost implications Impact on reputation Board compliance register Access to Accreditation Standards, Community Care Common Standards, guidelines. Policies and Procedures Residential and Community Care self assessment Audit Program Management training Legal & Regulatory Compliance Non compliance with Aged Care Act / Retirement Villages Act / Other Access to legislation, funding agreements, contracts, program guidelines Produced by Aged and Community Services Assoc of NSW & ACT : Nov 2012 Page 5 of 22

6 Legislation Breach in Act / legislation Current to Reduce, Mitigate or Transfer Policies and Procedures Communication through committee structure Member ACS / ANSTAT Board compliance register Audit program Board, Management & Staff training Legal & Regulatory Compliance: Inability to provide a safe work environment Injury or harm to staff, volunteers, contractors, visitors. Policies and Procedures Management and staff training Induction program WHS inspections to identify and manage risks / Annual Safety Inspections Hazard management system to identify and manage risks Security systems Smoke free environment: documented policies and procedures Purchase of appropriate equipment and equipment maintenance Produced by Aged and Community Services Assoc of NSW & ACT : Nov 2012 Page 6 of 22

7 Current to Reduce, Mitigate or Transfer Legal & Regulatory Compliance: Industrial relations issues Industrial disputes interrupt / delay work force Access to ACS industrial relations team for advice Human resource policies and procedures Induction program Maintain supportive work environment to maintain staff morale Legal & Regulatory Compliance: inadequate or inappropriat e insurance Inability to pay compensation Adequate insurance Regular insurance review Governance: Board Dysfunction Board dysfunction or lack of systems / knowledge to Govern organisation impacting on all aspects of business Constitution includes Governance Framework Governance policies and procedures Board training Defined KPIs and Board reporting Information Technology: Network problems/ All computers are linked to the Produced by Aged and Community Services Assoc of NSW & ACT : Nov 2012 Page 7 of 22

8 IT Malfunction failures Inability to access systems, loss of data or privacy breach Current to Reduce, Mitigate or Transfer main server and backed up daily Professional IT support services Regular and planned IT hardware and software upgrade Security systems in place Disaster Management : Fire, Flood, Natural disaster Natural disaster resulting in destruction of building and equipment Comply with building code: issued with Building certificate. Fire detection system Fire safety equipment in place and inspected every 6 mths or as required. Sprinkler system Preventative maintenance program Emergency response plan Cleaning procedures and external environmental cleaning reduces risk of fire. WHS inspections to identify environmental hazards. Significant grievance or Significant disputes leading to high level Grievance and complaints policy and procedure Produced by Aged and Community Services Assoc of NSW & ACT : Nov 2012 Page 8 of 22

9 disputes of dissatisfaction, impact on staff morale, impact on organisation reputation and costs Current to Reduce, Mitigate or Transfer Access to external complaints process Staff and Management training in Complaint Management Engage key stakeholder input and feedback through committee structure, surveys and open door policy Management over commitment Management over commit time and resources to individual process to the detriment of other processes Defined accountability of Senior Management Team to monitor performance across entire organisation Define key performance indicators monitored for key areas: Quality, workforce, financial, client. Communication processes Reporting processes Workforce Staff skills Staff do not have the knowledge and/ or skills to provide for individual care recipient care needs Recruitment procedures in place Position descriptions define accountabilities, roles and responsibilities All Care Staff have Cert III or Produced by Aged and Community Services Assoc of NSW & ACT : Nov 2012 Page 9 of 22

10 Current to Reduce, Mitigate or Transfer higher and appropriate experience. Defined training requirements Orientation & training program in place Allied Health / Registered Nurse registration Client assessment, care planning and evaluation process Care recipient assessment and care plan process identify specific care needs requiring specific knowledge and skill link to training program. Access to Registered Nurse for clinical assessment and staff training Referral process Brokerage agreement Inadequate staff levels Inadequate staff to fill the roster. Staffing levels not adequate to meet care recipient care needs. Recruitment procedures in place Roster management process in place Adequate staff pool to cover leave Produced by Aged and Community Services Assoc of NSW & ACT : Nov 2012 Page 10 of 22

11 Current to Reduce, Mitigate or Transfer Access to Agency / Brokerage services Care recipient assessment, monitor care needs and adjust staffing in line with care recipient acuity Monitoring of care indicators to ensure adequate staffing eg Client, care recipient, staff feedback, incidents, clinical indicators, complaints. Inability to recruit staff / High staff turnover Inability to provide adequate staffing Increased workload for existing staff Staff burnout Loss of productivity Absenteeism Flexible and supportive work environment to encourage staff to remain Codes of behaviour / conduct Career development opportunities Recruitment procedures Community public relations Fire / Emergency Numerous causes of house/ facility fires. Injury or death as a result of fire. Emergency response policy & procedure Emergency response and fire safety training for staff Evacuation drills Adequate staff levels in event of Produced by Aged and Community Services Assoc of NSW & ACT : Nov 2012 Page 11 of 22

12 Current to Reduce, Mitigate or Transfer an emergency, including on call roster Smoke free environment: documented policies and procedures Transport Motor vehicle accidents including injury or harm to care recipient or staff Vehicle damage All staff require current NSW / ACT Drivers Licence Register maintained with staff drivers license Motor vehicle insurance Purchase of appropriate vehicles in accordance with care recipient care needs eg. Wheelchair locks Regular service of vehicles Hazardous Chemicals Spills, consumption by clients Current Material Data Sheets (MDS) Staff, visitor, client injury Secured storage Staff training Chemical spill kit Approved list of chemicals for use in Community Care Staff Injury Work related WHS policies & procedures Produced by Aged and Community Services Assoc of NSW & ACT : Nov 2012 Page 12 of 22

13 Current to Reduce, Mitigate or Transfer injuries Care recipient assessment and care plan including behaviour management Staff pre-employment medical assessment Employment checklist includes immunization status Staff wellness program Staff immunization program Safe Work Method statements WHS, IC & MH training Injury Register Worker Compensation Incident management system Hazard management system WHS inspection to identify hazards Home safety inspection Pets in clients home Staff injury from pets Policies and procedures Home safety inspection identifies risk associated with client pets Staff working alone Staff on own at night, risk of security breaches Policy and procedure Emergency procedures Produced by Aged and Community Services Assoc of NSW & ACT : Nov 2012 Page 13 of 22

14 Community staff travelling on own to remote areas Staff entering clients home on own risk of personal injury associated with aggression Current to Reduce, Mitigate or Transfer Staff working alone have access to portable phone / mobile phone if required to ring in an emergency al security alarm if appropriate Regular vehicle service Home safety inspection Client assessment identifies at risk behaviours SERVICE USER RISKS Care recipient care needs not met Care not delivered in accordance with care recipient needs leading to neglect, harm or illness Policies and procedures for assessment and care planning Assessment and care planning tools in place Staff training in assessment and care plan process Care review process Access to Registered Nurse for clinical support Case conference Staff have knowledge and skill to provide the care Training & competency program Produced by Aged and Community Services Assoc of NSW & ACT : Nov 2012 Page 14 of 22

15 Current to Reduce, Mitigate or Transfer Access to external services Referral process Monitoring of care indicators Audit program Clinical governance procedures Increasing complex care needs Service not able to meet increasing care needs Security of tenure policy and procedure Entry / exit criteria Care recipient Assessment, care planning process and evaluation of care delivery Case conference process Policies and procedures for complex care needs Staff training and competency program Access to Registered Nurse, Allied Health and Other Specialist eg DBMAS / Palliative Care Audit program covers complex health care needs Monitoring of clinical indicators eg. Wounds, pressure areas, Produced by Aged and Community Services Assoc of NSW & ACT : Nov 2012 Page 15 of 22

16 Current to Reduce, Mitigate or Transfer unmanageable pain, unintentional weight loss, S8 medication management, restraint, behaviours of concern. Referral / transitional process Abandonmen t of the client Family/carer refuse to return to collect the care recipient at end of respite period Referral and assessment processes Majority of carers and care recipients known to service Emergency contact details Elder Abuse Residents / Clients physically, emotionally, socially or sexually abused Policies and procedures Assessment and ongoing care recipient monitoring All staff / volunteers with unsupervised access have current criminal record check Incident reporting system Mandatory reporting register (Residential) Staff orientation and training program Employee and Care Recipient manuals Produced by Aged and Community Services Assoc of NSW & ACT : Nov 2012 Page 16 of 22

17 Current to Reduce, Mitigate or Transfer Falls Client / resident falls, stumble, trips in facility or at home. of injury. Client / resident does not use appropriate equipment when mobile. Policy and procedure including falls prevention & management Falls risk assessment on all care recipients on admission, annually or if significant change in care needs Care recipient care plan includes falls prevention and management Clients supervised when mobile and on slippery or uneven surfaces where required Adequate staff levels to manage falls risk Hazard system in place to identify environmental fall hazards WHS inspections to identify environmental hazards Care recipients / carers provided with falls prevention information Home safety checklist completed and explained to community care clients Falls/near misses reported by staff so that additional Produced by Aged and Community Services Assoc of NSW & ACT : Nov 2012 Page 17 of 22

18 Current to Reduce, Mitigate or Transfer preventive measures are put in the care plan for specific service users Falls monitoring as a care indicator Care recipients with aggressive or wandering/ absconding behaviours Staff or others injury or harm Care recipient can wander / abscond from facility placing themselves in danger Emergency procedures include aggression Behaviour management policy and procedures Missing persons policy and procedure (Residential) Identification bands for people know to wander / abscond Eligibility criteria appropriate for service Assessment and care plan process with development of behaviour management plan if indicated Access to expertise eg. Psychogeriatrician, DBMAS Access to behaviour management resources Referral process Staff training Produced by Aged and Community Services Assoc of NSW & ACT : Nov 2012 Page 18 of 22

19 Current to Reduce, Mitigate or Transfer Incident management system, monitors trends in behaviours Care recipient file audits to ensure assessments and care plans reflect care recipient needs Unsafe / incorrect administratio n of medication Incorrect medication provided/given leading to side effects, illness, death. Medication policy and procedure Access to Best Practice resources for medication in Residential Aged Care and Community Care Prescription medications are only administered to individuals from clearly marked dose administration aids prepared by the Pharmacist Access to Registered Nurse for the administration of Schedule 8 medications Access to Endorsed Enrolled Nurse for administration of Schedule 4 medication, enema, suppository, Intramuscular. Safe storage of medications Staff supported to attain unit of Produced by Aged and Community Services Assoc of NSW & ACT : Nov 2012 Page 19 of 22

20 Current to Reduce, Mitigate or Transfer competency Physically Assist With Medication Administration Ongoing staff training & annual internal competency assessment Medication incidents reported, monitored and actioned. Food Borne Illness Food safety program not complied with Spoilt food prepared for consumption, hygiene practices not adhered to. Care recipient allergic reaction if served allergenic foods. Food borne illness may result in illness or death. Food safety program Food safety policy & procedure Access to food safety resources Assessment and care plan process to identify allergies to food Staff training Audit program NSW Food Authority Licence where required NSW Food Authority audit / ACT Health inspections where required Transmission of infection Transmission of Infection/s leading to illness of staff, Infection control policies and procedures in place Infection control resources Produced by Aged and Community Services Assoc of NSW & ACT : Nov 2012 Page 20 of 22

21 care recipients, others through poor infection control practices Current to Reduce, Mitigate or Transfer available Outbreak management packs (Flu & Gastro) available Access to personal protective equipment Access to hand washing / sanitiser Sharps disposal containers Care recipient assessment Infection surveillance monitored and analysed Staff orientation and training program Audit program includes infection control audits Fire Numerous causes of house fires Injury or death as a result of fire Property damage as a result of fire As per organisational / workforce risks Evacuation kit Smoke alarms mandatory in all client homes Staff training Natural Disaster or Not prepared, lack of procedure Policies and procedures including emergency response Produced by Aged and Community Services Assoc of NSW & ACT : Nov 2012 Page 21 of 22

22 threat of natural disaster Extreme weather Conditions resulting in staff, client or resident injury. Isolation, limited access to service Limited access to community clients to provide service Inadequate insurance Current to Reduce, Mitigate or Transfer and Care for client in extreme weather conditions: Heat wave Emergency Response Plan Air conditioning, curtains etc (increase fluids), cold climate. Links to Emergency Services, SES, Fire Brigade (alert system re; fire), Ambulance, Access to emergency medical services and hospital services. Access to police via phone or other system. Care recipient individual emergency plan Produced by Aged and Community Services Assoc of NSW & ACT : Nov 2012 Page 22 of 22