Quality and Engagement Sub Committee

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1 Quality and Engagement Sub Committee 12 June 2012 Corporate Risk Register and Risk Management Strategy Executive Summary As part of authorisation, Blackpool Clinical Commissioning Group (CCG) must identify and own the risks associated with being an NHS commissioning organisation. At present this includes risk associated with transition both to a CCG and as other functions from PCT structures transfer to external organisations. Risk management is a key part of risk ownership. The aims of the risk management strategy are to ensure the risks to employees, reputation, finances, commissioned services and business continuity of the CCG are protected through the process of risk identification, assessment, control and where possible elimination. The existing Risk Management Strategy has been reviewed and a draft is attached for consideration. The CCG received a Corporate Risk Register at the May 2012 Quality and Engagement Sub Committee. The updated version of the risk register is for information. Attached ( appendix 1) is a list of relevant risk related policy documents for adoption (and review) and a draft Risk Management Strategy for approval by the CCG. Recommendation That the Quality and Engagement Sub Committee: Note the CCG corporate risk register Consider the CCG risk management strategy for approval by the CCG Board Note and approve the policies to be adopted and reviewed in preparation for CCG authorisation Keith Savage Head of Risk Management

2 Appendix 1 (Risk Management) Policies Policy Title Status Review Date Originating Organisation Risk Management Strategy Revise June 2012 NHS Blackpool Safeguarding Children Strategy Adopt April 2013 NHS North West Fraud and Corruption Adopt September 2012 NHS Blackpool Safeguarding children and adults Adopt June 2012 NHS Blackpool policy Claims Policy Adopt March 2014 NHS Blackpool Complaints Policy Review September 2012 NHS Blackpool SUI Performance Management Adopt December 2013 NHS Lancashire Policy Health and Safety Policy Adopt December 2014 NHS Lancashire Fire Policy Adopt December 2014 NHS Lancashire Lockdown Policy Adopt August 2013 NHS Blackpool (H&S 27) Incident Reporting Adopt January 2013 NHS Blackpool (H&S 7) Health and Safety Strategy Adopt March 2013 NHS Blackpool Serious Untoward Incidents Adopt September 2012 NHS Blackpool (H&S 7a) Lone Working Policy Adopt May 2012 NHS Blackpool (H&S 9) Moving and Handling Policy Adopt September 2012 NHS Blackpool (H&S 10) Pregnancy Policy Adopt September 2012 NHS Blackpool (H&S 12) Violence Policy and Procedure Review December 2012 NHS Blackpool (H&S 13a) Bomb Threat and Suspect Packages Adopt June 2012 NHS Blackpool (H&S 16) Security Policy Adopt July 2012 NHS Blackpool (H&S 17) Stress Policy Adopt August 2012 NHS Blackpool (H&S 18) Being Open Strategy Adopt May 2012 NHS Blackpool (H&S 20) Risk Assessment and Risk Registers Adopt September 2012 NHS Blackpool (H&S 23) Statutory and Mandatory Training Review December 2012 NHS Blackpool (H&S 24) Medical Devices Policy New June 2012 NHS Blackpool External Agency Visits Review June 2012 NHS Blackpool Subject access Adopt NHS Lancashire Data protection and Confidentiality Adopt NHS Lancashire Information security policy Adopt NHS Lancashire

3 RISK MANAGEMENT STRATEGY Date of Approval: June 2012 Approved by: Quality and Engagement Sub Committee Review Date by: June 2015 RISK MANAGEMENT STRATEGY 2012 TO 2015

4 I N D E X O F C O N T E N T 1.0 Introduction 2.0 Aims 3.0 Strategic Intent 4.0 Scope of the Strategy 5.0 Culture of the Organisation 6.0 Benefits of Implementing The Risk Management Strategy 6.1 Assurance Framework 7.0 Risk Management 7.1 Risk Definition 7.2 Risk Management Process 7.3 Risk Evaluation 7.4 Recording Risk 8.0 Claims and Complaints 9.0 Safeguarding 10.0 Implementation Risk Categories 12.0 Structures for Risk Management 12.1 Structure B Committee Roles to be Included 13.0 Responsibility for Risk Management C Individual Roles to be Included 14. All Managers 15. Responsibilities of All Staff, Including Agency & Locum 16. Risk Management Key Performance Indicators 17. Monitoring Arrangements for Risk Management

5 18.0 Risk Management Objectives for 2012 to Information Governance 20.0 Equality Impact Assessment

6 List of Appendices Appendix 1 - Glossary of Terms Appendix 2 - Committee Structure (New Structure) Appendix 3 - Risk Matrix

7 BLACKPOOL CCG RISK MANAGEMENT STRATEGY 1.0 Introduction Blackpool CCG is aware of all significant risks and can allocate resources appropriately, in a prioritised way, to manage risk and ensure that the CCG meets its objectives. The risk management process supports the CCG s determination to commission services people need in a way that makes best use of financial resources, to nationally consistent standards of quality and safety. The CCG will ensure that decisions made on behalf of the organisation are taken with consideration to the effective management or risks. The Management of Health and Safety at Work Regulations 1999 and the Workplace (Health and Safety at Welfare) Regulations 1992 (as amended 2002) require that all employers ensure that assessments of health and safety risks to employees, the organisation and anyone else who may be affected by their practices or procedures are carried out and reviewed at regular intervals to ensure they remain valid. Additionally the Corporate Manslaughter and Corporate Homicide Act 2007 requires senior management to take reasonable steps to protect employees and anyone else who may be affected by any risk associated with their practices or procedures. The implementation of robust risk management systems is of paramount importance. 2.0 Aims Blackpool CCG through the Data Protection Act 1998 and the Freedom of Information Act 2000 shall comply with rules relating to the handling of information. The aims of the strategy are to ensure the risks to employees, reputation, finances, commissioned services and business continuity of the CCG are protected through the process of risk identification, assessment, control and where possible elimination. 3.0 Strategic Intent The CCG recognises that Risk Management is an integral part of effective management practices and, to be most effective, must be embedded within the culture of Blackpool CCG. The CCG is committed to a strategy that reduces risk to an acceptable level to all its stakeholders through this comprehensive Risk Management Strategy, which allows for flexibility, innovation and best practice and the delivery of its strategic objectives.

8 4.0 Scope of the Strategy This document applies to all employees of the CCG including locum and agency staff. Managers at all levels are expected to take an active lead to ensure that risk management and systems of internal control are of the highest standard and integral to the operation of the organisation. 5.0 Culture of the Organisation Risk is the uncertainty of outcome of an event which could have a positive or negative result. Unfortunately risk is usually seen as negative with consequences that need to be avoided. To meet its demanding targets the organisation requires to take measured risks, it is only by being innovative that it will meet the challenges faced by the CCG. As a principle the CCG will seek to eliminate, reduce and control risks but recognises that it is impossible and not always desirable to eliminate all risks. Therefore, the CCG may explicitly decide, on a case by case basis, to agree a level of acceptable risk for a particular project or operation. Risks scored at Low or Very Low on the Risk Matrix (numerical score of 8 or less) would be acceptable to the CCG and managed within the specific service. Occasionally, despite our best efforts, things can go wrong and it is important that risk management is about promoting a just, fair and positive culture which fosters learning and improvements as a result of risk identification or occurrence of untoward incidents. All efforts will be made to avoid cover ups of untoward incidents, mistakes or near misses and the overall approach within the CCG shall be one of help and support to each other, rather than recriminations and blame. The CCG is committed to this fair approach. By adopting this stance, the CCG aims to promote an accountability culture which is just and fair to the staff and enables the CCG to learn from events and situations in order to continuously improve management processes and where necessary change policy/procedure to enable this to happen. 6.0 Benefits of Implementing the Risk Management Strategy Effective Risk Management supports the achievement of organisational aims, objectives and targets Minimise waste, fraud, error and supports effective use of resources Supports robust policy formulation Assists business continuity Successful commissioning of services to patients, wider community and other external organisations Encourages compliance with relevant laws and external enforcing agencies Supports propriety and regularity of expenditure Supports better decision making Supports better project management Supports effective change management

9 6.1 Assurance Framework The organisation structure is supported by the Corporate Risk Register. Through review of the Risk Register the CCG gains assurance from others that risks to the achievement of the organisation s objectives are being appropriately managed throughout the organisation. The Risk Register is a dynamic live document which is updated to reflect changes in risk and controls exercised. In this respect the document is updated and presented to the Quality and Engagement Sub Committee. 7.0 Risk Management 7.1 Risk Definition Blackpool CCG defines risk as; "Anything that could cause harm to stakeholders to whom we owe a duty of care, or threatens the achievements of our strategic objectives. This includes damage to the reputation of the Trust that could undermine public confidence". A glossary of terms used for Risk Management is detailed in Appendix Risk Management Process The CCG operates two major systems to facilitate the management of risk throughout the organisation: Proactive risk management, via the risk assessment process (Health and Safety Policy: Guidance on Carrying Out Risk Assessments and Populating Risk Registers) Reactive risk management, via the incident reporting process (Health and Safety Policy: Untoward Incident Reporting and Investigation) Both systems use the same risk grading matrix Appendix 3 in order to assess risks consistently across the organisation in terms of Likelihood and Consequence 7.3 Risk Evaluation The Risk Management Process being implemented by the Trust is based on the Australian Standard Risk Management AS/NZS 4360:1999 This methodology allows the systematic and quantifiable assessment, recording and treatment of risks. The process can be applied to any level in the CCG and to any procedure, project or decision. Adequate records must be maintained at each stage of the process, capable of being verified by independent audit.

10 COMMUNICATION & CONSULTATION MONITOR & REVIEW ESTABLISH CONTEXT IDENTIFY RISKS ASSESS RISKS ANALYSE RISKS EVALUATE & RANK RISKS TREAT RISKS RISK REGISTER The main elements of the above process are defined below: Establish context Establish the strategic, organisational and risk management context in which the rest of the process will take place. Criteria against which risk will be evaluated are established and the structure of the analysis defined. Identify risks Identify what, why and how things can arise as the basis for further analysis. Analyse risks Determine the existing controls and analyse risks in terms of consequence and likelihood in the context of these controls. The analysis should consider the range of potential consequences and how likely they are to occur. Consequence and likelihood may be combined to produce an estimated level of risk. Evaluate and rank risks Compare estimated levels of risk against preestablished criteria. This enables risks to be ranked so as to identify management priorities. If the levels of risk established are low then risks may fall into an acceptable category and treatment may not be required. Treat risks Accept and monitor low priority risks. For other risks, develop and implement a specific management plan (action plans), which include cost considerations. Monitor and review Monitor and review the performance of the risk management system and changes which might affect it. Communicate and consult Communicate and consult with internal and external stakeholders as appropriate at each stage of the risk management and overall process.

11 7.4 Recording Risks All CCG members are responsible for ensuring that risk assessments are undertaken which will form the basis of the Risk Register. The risk assessment shall encompass a holistic approach to include Health and Safety, Clinical, Non Clinical Information Governance and Financial risk. The risk register will be compiled for the CCG and reviewed at the Quality and Engagement Sub Committee. The risk register is a prioritised list of risks identified to the CCG through the risk assessment process. It will be a dynamic document that details the organisation's risk profile at any given time. 8.0 Claims and Complaints There is an agreed process and procedure for reporting, managing, analysing and learning from complaints and claims which is in accordance with NHS guidelines. Regular reports of complaints and claims received by the CCG will be presented through the Quality and Engagement Sub Committee. We will actively seek feedback from patient groups, survey data and local PPI forum to identify safety issues and help improve and inform commissioning decisions. 9.0 Safeguarding We will maintain the agreed procedures and safeguarding arrangements in place locally. We will actively participate in Safeguarding Boards and case reviews and actively support partner agencies to protect vulnerable people in Blackpool. The Board Nurse will be the lead person on the governing body responsible for ensuring that there are clear lines of accountability for safeguarding within the CCG. The CCG will have senior representatives on the local Safeguarding Boards to promote management commitment and awareness Implementation The effective implementation of the Risk Management Strategy will facilitate the commissioning and delivery of a quality service. The CCG will, Ensure all employees and stakeholders have access to the Risk Management Strategy Produce risk registers across the organisation which will be subject to routine review Communicate to employees any action to be taken in respect of risks identified Develop policies, procedures and guidance based on the results of assessments and all identified risks to assist in the implementation of this strategy Provide new employees with induction training including Health and Safety, fire, incident reporting, risk assessment and general risk management.

12 Provide all employees with update training in Health and Safety, incident reporting, risk assessment, fire, manual handling and other training as required. Ensure that employees have the knowledge, skills, support and access to expert advice necessary to implement the policies procedures and guidance associated with this strategy. Traditionally within the NHS risk has been identified as clinical or physical and latterly strategic or operational. With a greater awareness of risk comes a greater understanding of risk categories which will help to provide a structure and framework to allocate accountability and responsibility more effectively Risk Categories Risk Category Change Financial Governance Legal and Compliance Operations Information and Technology People Strategic Definition These concern risks that programmes and projects do not deliver agreed benefits on the line and within agreed budget and or/introduce new or changed risks that are not effectively identified and managed. These concern the effective management and control of the finances of the CCG. The risk events can range from insufficient funding, poor budget management, mismanage assets and liabilities. These concern the establishment of an effective organisational structure with clear lines of authorities and accountabilities. The risk events can include inappropriate decision making and delegation of authorities. All can result in sub optimal performance and losses for Blackpool CCG. These concern such as H&S, consumer protection, data protection, employment practices, failing to comply with employment legislation or industrial action, claims against Blackpool CCG, and regulatory issues These concern the day to day concerns Blackpool CCG is confronted with as it strives to deliver its strategic objectives. They can be anything from loss of key staff to process failure. It covers risk events such as failure by A 3 rd party to deliver a service for the operation, breakdown in partnership with 3 rd party, failure to manage internal change etc. Operational risks are largely short to medium term where frequency is high/medium likelihood and low to high impact. These concern the day to day issues Blackpool CCG is confronted with as it strives to deliver its strategic objectives. They can be anything from loss of data to failure of a key IT system. It covers risk events such as technological breakdown, loss of hard or soft copy data, failure by a 3 rd party to deliver a service, breakdown in partnership with 3 rd party, failure to manage internal change etc. These concern insufficient staff resources (capacity and capability). These risks can have a significant impact to the performance and reputation of Blackpool CCG These concern the long term strategic objectives of the CCG. They can be affected by external factors such as the economy, changes in the political environment, technological changes, and changes in legal and regulatory changes. The strategic risks are mainly significant risks that can potentially impact the whole CCG. They are also in a lot of cases cross cutting risks the impact across the CCG rather than just one area.

13 Clinical Reputational Risk These concern risks that arise directly from the commissioning of healthcare to patients. This includes safeguarding, clinical errors and negligence, healthcare associated infection and failure to obtain consent. It is important that the reputation of the CCG is protected through the process of robust systems of communication with stakeholders. Systems of communication with external stakeholders that contribute to minimise risk are in place, including regular meetings, customer satisfaction surveys publications and public meetings. The CCG has a large and divers range of stakeholders and they will seek to improve the effectiveness of its engagement with each group Structures for Risk Management Structure In order to ensure that the risk management and external assurances are adhered to, the Blackpool CCG has developed a structure with clear lines of responsibility and accountability. Appendix 2 depicts the key established groups committed to support risk management and external assurances within the CCG. Details of the roles and responsibility of each group are outlined below. B 13.0 Responsibility for Risk Management It is a fundamental tenet of this Strategy that, whilst overall accountability and responsibility for risk management lies with the Chief Operating Officer, it is also the responsibility of all CCG members and managers to manage risks. It is also important that managers at all levels stimulate the interest of their staff in the identification and reporting of hazards and risks which exist and that managers address these proactively. Additionally, all managers are expected to ensure that any adverse incidents and near misses, which occur in their areas of responsibility, are reported immediately, through the agreed reporting systems, and responded to positively. An untoward incident reporting Policy and Procedure is used for this purpose. The overall risk management responsibilities of managers and staff are outlined below. C 14. All Managers All Managers are responsible for ensuring that risk management is an integral part of the management process within their area of responsibility. They have a responsibility for ensuring that risk management tools e.g. Risk assessment and incident reporting are used effectively. All Managers must ensure that identified risks within their area of responsibility are actioned. Identified risks that can be adequately controlled using local control measures and resources must be addressed

14 locally. Where a risk is identified, or local control measures would not suffice in the management of the identified risk. It may then escalate for inclusion onto the Corporate Risk Register. 15. Responsibilities of All Staff, Including Agency and Locum All staff employed by Blackpool CCG must manage risk within their own area of responsibility. Ideally this should include attending mandatory and statutory training, reporting incidents, assessing risks, reporting unsafe occurrences and compliance to policies. All staff have a statutory duty to take reasonable care of their own safety and the safety of others who may be affected by their acts or omissions. To ensure that all staff are aware of their responsibilities for risk management, objectives in relation to risk management must be set for individuals through their personal development plan. (PDP). 16. Risk Management Key Performance Indicators The Risk Management performance devised to ensure that the Trust embeds a safety culture throughout the organisation is audited through these indicators: Target External Assurances:- NHSLA, CQC, Pro-active risk management Re-active risk management Employee Support Key Performance Indicator Monitor compliance to assurances through audit programmes, ensure action plans of deficiencies are implemented effectively and in a timely manner through the Quality and Engagement Sub Committee Regularly review (as specified in appropriate policy) of corporate risk registers by the Quality and Engagement Sub Committee.. Review, investigate and analyse incidents and share lessons through the Quality and Engagement Sub Committee. Provide Risk Management Training analyse and untoward incident trends through the Quality and Engagement Sub Committee Monitoring Arrangements for Risk Management Assurances, assessments and risk management key performance indicators will be monitored through the Quality and Engagement Sub Committee.

15 18.0 Risk Management Objectives for 2012 to Objectives Date for Attainment Responsible Manager 1. To continue active collaboration across the Health Economy and with other statutory organisations. 2. To ensure there is access to a Risk Management Training Programme. Ongoing Ongoing 3. To review Serious Untoward Incidents on StEIS and Performance Management of Service Providers including safeguarding where CCG is the lead commissioner. 4. To approve, disseminate and implement the Risk Management Strategy. Ongoing July To update the CCG and relevant subcommittee and External Agencies with areas of significant risks. Ongoing 6. To maintain the development of structures and processes to create a consistent and cohesive approach to integrated Risk Management. 7 To ensure Risk Management Policies and Procedures are up to date and implemented. Ongoing Updated Bi-Annually 8 To raise awareness of Risk Management Ongoing 9. To review the Untoward Incident Reporting System, including associated procedures, in line with the National Patient Safety Agency s recommendations. Ongoing 10. To annually review Risk Management processes. 11. To populate both the Corporate Risk Registers to comply with external assurances and maintain the local Risk Management database. March 2013 Quarterly Update

16 12. To work closer with partner agencies Police Authority, Fire Authority, Blackpool Borough Council as Blackpool Community Safety Drugs Partnership to consider actions that will promote safeguarding, reduce crime and disorder, improving community safety and complying with the CCG s statutory requirement of the Crime and Disorder Act 1998 section To raise awareness of the CCG to the Corporate Manslaughter and Corporate Homicide Act To support the CCG /Trust s Corporate Objectives 15. To maintain compliance with NHS Security Management Services requirements 16. To maintain compliance to all statutory and mandatory requirements of external agencies and enforcing authorities. Ongoing Oct-12 Ongoing Ongoing Ongoing Achievement of these objectives will require the co-operation and involvement of all staff at all levels of the organisation 19.0 Information Governance Information Governance exists alongside Clinical Governance and Risk Management and sets the standards required of the CCG to ensure that all its information handling processes are undertaken to meet legal, ethical and quality compliance. For each of the standards there is an associated risk to the organisation when compliance is not met. An assessment of the risk associated with each standard provides and indicator of the priorities for action in order to minimise potential breaches of confidentiality and security and to ensure that guidance is available and accessible to staff in policies and procedures to meet all information quality assurance standards Equality Impact Assessment This policy has been assessed with consideration to the Race Relations (amendment) Act 2000, to establish the likely equality implications on the population it serves. This strategy sets the strategic direction for Risk Management within Blackpool CCG for the next year but will respond to developments and initiatives as required by internal and external forces. KEITH SAVAGE

17 GLOSSARY OF COMMON RISK MANAGEMENT TERMS Appendix 1 Complaint: Consequence: External Assurance: Cost: Event: Frequency: Hazard: Incident: Incident Reporting and Investigation: Likelihood: Loss: Monitor: Organisation: Action taken by a patient or client of a healthcare facility, or his or her agent, to communicate dissatisfaction or concern about any aspect of care, treatment or experience. The outcome of an event, being a loss, injury, disadvantage or gain in respect of the physical, emotional, financial, social or credibility status of the individual or organisation. A process designed to provide evidence that the NHS in total and its constituent parts is doing its reasonable best to manage, direct and control itself so as to protect itself, its employees', patients and stakeholders' safety and interests against risk of all kinds. Activities, both direct and indirect, which result in a negative outcome or impact for an individual or the organisation - cost includes money, time, labour, disruption, and goodwill, political and intangible losses. An incident or situation occurring in a particular place during a particular interval of time. A measure of the rate of occurrence of an event expressed as the number of occurrences of an event in a given time. A source of potential harm or a situation with the potential to cause loss. Any unplanned event or circumstance resulting in, or having a potential for, injury, ill health, complaint, claim, damage or loss. A formal structured process and approach to enable the occurrence of incidents to be reported, recorded and the root cause of reported incidents identified, in order to manage risk exposure and identify corrective actions. A qualitative measure or description of probability or frequency. Any negative consequence, financial or otherwise. To check, supervise, observe critically or record the progress of an activity, action or system on a regular basis in order to identify change. A NHS Trust, company, firm, enterprise or association etc.,that has its own function(s) and administration.

18 Appendix 2 RISK REPORTING STRUCTURE Clinical Commissioning Group Quality and Engagement Sub Committee Finance and Performance Sub Committee PPI Forum Blackpool Adult Safeguarding Board Blackpool Children s Safeguarding Board

19 Matrix Consequence Score Appendix Descriptor Insignificant Minor Moderate Major Catastrophic Injury to staff or patient Minor injury not requiring first aid Short-term, minor injury or illness, first aid treatment needed. Resolved within one month. RIDDOR reportable, semipermanent injury/damage, takes up to one year to resolve Major injuries, or long term incapacity / disability (loss of limb) Death or major permanent incapacity Patient Experience Complaint / claim Potential Objectives / Projects Unsatisfactory patient experience not directly related to patient care Locally resolved complaint Insignificant cost increase / schedule slippage. Barely noticeable reduction in scope or quality Unsatisfactory patient experience readily resolvable Justified complaint peripheral to clinical care < 5% over budget / schedule slippage. Minor reduction in quality / scope Mismanagement of patient care short term effects Below excess claim. Justified complaint involving lack of appropriate care 5 10% over budget / schedule slippage. Reduction in scope or quality requiring client approval Mismanagement of patient care long term effects Claim above excess level. Multiple justified complaints 10 25% over budget / schedule slippage. Doesn t meet secondary objectives Totally unsatisfactory patient outcome or experience Multiple claims or single major claim > 25% over budget / schedule slippage. Doesn t meet primary objectives Service / Business Interruption Human Resources / Organisational Development Loss / interruption > 1 hour Short term low staffing level temporarily reduces service quality (< 1 day) Loss / interruption > 8 hours Ongoing low staffing level reduces service quality Loss / interruption > 1 day Late delivery of key objective / service due to lack of staff (recruitment, retention or sickness). Minor error due to insufficient training. Ongoing unsafe staffing level Loss / interruption > 1 week Uncertain delivery of key objective / service due to lack of staff. Serious error due to insufficient training Permanent loss of service or facility Non-delivery of key objective / service due to lack of staff. Loss of key staff. Very high turnover. Critical error due to insufficient training Financial Small loss (> 100) Loss > 1,000 Loss > 10,000 Loss > 100,000 Loss > 1,000,000 Enforcement Action. Low Minor Recommendations Reduced rating. rating. Critical Prosecution. recommendations. given. Noncompliance Challenging report. Multiple Zero rating. Minor noncompliance with recommendations. challenging Severely critical with standards Non-compliance recommendation report standards with core s. Major noncompliance standards with core standards Inspection / Audit Adverse Publicity / Reputation Rumours Local Media short term Local Media long term National Media < 3 days National Media > 3 Days. MP Concern (Questions in House)

20 Risk Matrix Likelihood score Descriptor Rare` Unlikely Possible Likely Almost Certain Frequency Probability Not expected to occur for years Expected to occur at least annually Expected to occur at least monthly Expected to occur at least weekly Expected to occur at least daily < 1% 1 5% 6 20% 21 50% > 50% Will only occur in exceptional circumstances Unlikely to occur Reasonable chance of occurring Likely to occur More likely to occur than not Risk Rating Matrix Consequence Likelihood 1 Insignificant 2 Minor 3 Moderate 4 Major 5 Catastrophic 1 Rare 2 Unlikely 3 Possible 4 Likely Almost Certain Very Low Risk Unlikely to cause problems Low Risk Needs to be resolved or accepted at Departmental level* Medium Risk Needs to be resolved or accepted at Directorate level* High Risk To be resolved or accepted at Trust level * If the risk is not acceptable and cannot be resolved at the appropriate level, it needs to be fed to the next level.

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