RISK ASSESSMENT POLICY

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1 RISK ASSESSMENT POLICY Post holder responsible for Policy: Directorate / Department responsible for Policy: Contact details: Governance Manager Governance Noy Scott House ext Date written: August 2003 Date revised: October 2005 Approval route (names of committees): Governance Committee Board of Directors Date of final approval: 30 th November 2005 Date due for revision: November 2007 Date policy becomes live: 1 st December 2005 This document replaces: 2004 Controlled Document This document has been created following the Royal Devon & Exeter NHS Foundation Trust Policy on the creation of policies, procedures, protocols, guidelines and standards. It should not be altered in any way without the express permission of the author or their representative. Page 1 of 5

2 1 INTRODUCTION 1.1 The Royal Devon & Exeter NHS Foundation Trust recognises that risk assessment is a legal requirement under a range of health and safety legislation, notably the following:- Management of Health and Safety at Work Regulations 1999 Manual Handling Operations Regulations 1992 Provision and Use of Work Equipment Regulations 1998 Lifting Operations and Lifting Equipment Regulations 1998 Health and Safety (Display Screen Equipment) Regulations 1992 Noise at Work Regulations 1989 Control of Substances Hazardous to Health Regulations Further information regarding the above subjects is contained in the relevant Royal Devon & Exeter NHS Foundation Trust policies and procedures. 1.3 The process of risk assessment is designed to identify hazards and resulting risks. A hazard is something with the potential to cause harm (e.g. electricity) or the potential for not meeting an objective and risk is the likelihood and consequence of that harm actually occurring (e.g. low, medium or high risk of electric shock) and the severity of the harm (e.g. slight injury, major injury, death). 2 RISK REGISTER 2.1 Royal Devon & Exeter NHS Foundation Trust has adopted the concept of using a risk register to enable it to effectively manage the information surrounding risk assessment. This is a living document updated on a regular basis. 2.2 All significant risks i.e. those with a Risk Rating Number (RRN) >=16 will be collated and placed on the Trust Risk Register. This will be the primary source of information for the Trust to prioritise funding to mitigate all/some of the risk. 2.3 All Directorates will also maintain their own risk registers. These should also be living documents and enable them to effectively manage risks identified through risk assessment. Page 2 of 5

3 2.4 Directorates that have risks with a RRN >=16 should ensure that these risks are placed on the Trust Risk Register. 3 CONTINUAL RISK ASSESSMENT 3.1 Risk assessments will be carried out on a rolling basis, managed by Directorate managers. Risk officers will carry out risk assessment as they have been trained in this procedure. Directorate risk registers will contain information on current risk assessments and the Directorate Governance Groups will examine and act on these assessments. 4 ROLES AND RESPONSIBILITIES 4.1 Governance Committee reviewing the adequacy of systems for managing risk and the control environment throughout the Trust. promoting continuous quality improvement with regard to the management of risk. advising the Board of Directors on the risk considerations relevant to the agreement of strategic objectives and investment priorities. approving development plans for improving the Trust s management of risk prioritising the Trust's most significant risks and deciding on the level of resources required to manage those risks effectively. assisting the Medical Director to direct the clinical risk management process on behalf of the Chief Executive. in liaison with the Director of Finance, ensuring that integrated performance reports to the Board of Directors include an adequate range of risk indicators, and that these form a part of the Trust s systems for performance management. ensuring that the Trust meets all relevant legal and statutory obligations ensuring that the standards of the Clinical Negligence Scheme for Trusts (CNST) and the Risk Pooling Scheme for Trusts (RPST) are met at least at level 1 Page 3 of 5

4 preparing the annual statement on internal control for approval by the Board of Directors. commissioning reviews in areas of specific interest to the Committee. 4.2 Health & Safety Committee study accident/incident statistics and consider the circumstances and causes of accidents, dangerous occurrences, incidents and occupational illnesses (as specified by the Health and Safety Executive) and make recommendations and monitor action taken in order to prevent the recurrence of accidents, etc; make inspections of specific hazards in circumstances where the general interests of employees may be affected, to make appropriate recommendations for improvement in respect of health and safety welfare, and to monitor these improvements; concern itself with the arrangements for the effectiveness of safety training, instruction and guidance of all new and existing employees; consider regulations, codes of practice, reports and any other guidance information produced by the Health and Safety Executive or other government bodies, and to consider means whereby these can be introduced; secure the co-operation of all employees in the promotion of health and safety through the provision of adequate publicity in the workplace; consider and make recommendations as appropriate on any reports submitted by safety representatives. It should be noted that such reports will only be considered by the Committee in circumstances where the content of the report has been discussed with the appropriate line manager. 4.3 Risk Management ensures that training is provided to selected staff to enable them to become competent in the basic principles and techniques of risk assessment; provides assistance and support to those undertaking risk assessments and direct them to sources of specialist help and advice where necessary. Page 4 of 5

5 4.4 Occupational Health provide advice regarding the specific issue of risks to staff health in the workplace. 4.5 Managers are responsible for ensuring that risk assessments are carried out and reviewed at least annually, that they are aware of the results of those risk assessments and that they take follow-up action to eliminate/reduce the risks identified. This may involve referring the problem up the managerial line and informing Risk Management if necessary. Managers must also ensure that risk assessments are retained for ten years; must ensure that risk assessments on new activites in their areas are also carried out; must inform staff (and others where necessary) of the results of risk assessments and the control measures in place to eliminate/reduce the risk. Compliance with control measures should be monitored by managers to ensure their effectiveness. 4.6 Risk Officers Risk officers will carry out risk assessments in their areas and report the findings to their line manager 4.7 All staff should be aware of the results of risk assessments in their area and what they need to do personally to ensure compliance with control measures identified as being necessary. Examples of such action include following a safe system of work or wearing suitable personal protective equipment. Page 5 of 5

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