Risk Management Policy

Transcription

1 Risk Policy This policy sets out how the Risk Strategy will be implemented and should be read in conjunction with the Risk Strategy, Health and Safety Policy, Accident/Incident Reporting Policy and Fire Safety Policy. Document Number: EDQ012 Version: Version 6 Authorised by: Trust Board Date authorised: July 2010 Next review date: July 2013 Expiry Date: 30 June 2013 Document Author: Helen Curtis Governance Director

2 Pennine Acute Hospitals NHS Trust Risk Policy Main Revisions from previous issue Name of Previous Document: Document Number: Risk Policy EDQ012 Version Number: Version 5 Reason for Revision: Has undergone scheduled review; has been amended to reflect the work undertaken in conjunction with Ernst Young in preparation for Foundation Trust status; and has been amended to reflect changes to the board committee structure. Review Date: July 2013 Please ensure you have the latest version of this document 2 of 22

3 Contents Page(s) 1. Introduction 4 2. Accountability/Responsibility Risk Assessment Risk Rating 7 5. Risk Control/Principles of Prevention 7 6. Risk Register 8 7. Risk Register Process Training & Education 9 9. Accident/Incident Reporting Performance Monitoring and Provision of Information References Appendices Appendix A Risk Assessment Form Appendix B Schematic Representation 18 Appendix C Criteria For Escalation 19 Appendix D Trust Contact Numbers Appendix E Monitoring Compliance 22 Review Date: July 2013 Please ensure you have the latest version of this document 3 of 22

4 1.0 Introduction 1.1 The Pennine Acute Hospitals NHS Trust is committed to the provision of high quality services in environments that are safe for patients, staff and visitors alike. It acknowledges the importance of the identification, reduction and proactive management of all areas of risk to protect the Trusts services, staff, finances and reputation. 1.2 This policy sets out how the Risk Strategy (EDQ011) will be implemented and should be read in conjunction with the Risk Strategy, Health and Safety Policy (EDQ007), Accident/Incident Reporting Policy (EDQ008) and Fire Safety Policy (EDG012). 1.3 This policy will be reviewed every three years or when procedural, legislative or best practice changes occur. 1.4 The aim of the Trust is to minimise its exposure to clinical, financial and operational risk; the methodology for this is in accordance with sound risk management practices. 2.0 Accountability/ Responsibility 2.1 The Chief Executive has overall responsibility for the management of risk. 2.2 The Trust board will establish a number of committees, which will be chaired at Executive level and will report to the Trust Board. Clinical Risk is the responsibility of the Medical Director via the Clinical Governance and Quality. Clinical Risk will be facilitated by the Trust s Risk Co-ordinators. Financial Risk is the responsibility of the Director of Finance through the Finance. Operational Risk is the responsibility of the Operations Director through the Risk. Physical Risk is the responsibility of the Trust Safety Advisors. The Trust Safety Advisors will facilitate risk management issues relating to physical risk ensuring compliance with all health and safety regulations. Handling Risk - the Trust Manual Handling/Back Care Advisors will facilitate risk management issues relating to Moving and Handling Risk. Fire Risk - the Trust Fire Officers will facilitate risk management issues relating to Fire Risk. Review Date: July 2013 Please ensure you have the latest version of this document 4 of 22

5 2.3 Trust Board/Chief Executive/Medical Director To support and direct the Risk Strategy by: Demonstrating commitment to the Risk Strategy/Policy 2.4 Governance Director Regularly review progress in line with Risk Strategy/Policy Provide resources and guidance. 2.5 Risk Co-ordinators/ Health and Safety Advisors Report to the Divisional Governance s and Health and Safety s Monitor and investigate incident reports Assess organisational systems, policies and procedures, as required Communicate/liaise with appropriate personnel Assist Divisional, Directorate and Departmental Managers to instigate appropriate risk controls Maintain and update the Risk Register 2.6 Divisional Directors, Clinical Directors and Heads of Department Ensure risk assessments take place within their sphere of responsibility Divisional Directors are authorised to own and action all risks with a residual risk rating of moderate or below. Risks with a residual risk rating of high and above should be brought to the attention of the appropriate Executive Director. Ensure risk assessments are forwarded to the Health and safety Advisors/Risk Co-ordinators Ensure incident reports are completed for all incidents and near misses Review risk assessments and incident forms in order to implement action to eliminate/decrease the risk Seek advice from Health and Safety/Clinical Risk Co-ordinators and other relevant officers as required Instigate appropriate risk controls Ensure that all staff understand their responsibilities for risk management under legislation, risk management policies and procedures Ensure all staff comply with statutory regulations e.g. Manual Handling and RIDDOR Ensure staff compliance with Trust policies, protocols and procedures. Ensure attendance of staff at required training e.g. risk management training and Induction, and keep records of such training 2.7 Head of Claims/Claims Managers Review Date: July 2013 Please ensure you have the latest version of this document 5 of 22

6 Notify the NHS Litigation Authority of any reportable incident/complaints (potential claims), and claims Liaise with the legal advisors appointed by the NHS Litigation Authority Notify the Chief Executive, Director of Nursing, Medical Director and Governance Director of any claim considered to be novel, contentious or repercussive. Provide regular trend reports to the appropriate divisions, trust board and Governance s Communicate/liaise with Risk Co-ordinators, Health and Safety Advisors and Complaints Staff 2.8 Complaints Record and report all complaints in accordance with the NHS complaints procedure and Trust Complaints Policy Provide regular trend reports to the appropriate divisions, Trust Board and Governance s Communicate/liaise with Risk Co-ordinators, Health and Safety Advisors, Complaints Staff or other relevant officers. 3.0 Risk Assessment 3.1 The principal means by which risks that the Trust is exposed to can be properly controlled is via a proactive programme of assessment, using the format provided (see appendix A). Many such assessments will be carried out at local level, by ward or departmental managers. However risks affecting the divisions as a whole will need to be assessed at divisional level. 3.2 Assessments and measures taken by managers to ensure compliance should be made available to all relevant staff. 3.3 Upon completion of any risk assessment the documentation should be forwarded to the line manager or the designated site officer (see appendix B). 3.4 In performing a suitable and sufficient risk assessment, the following definitions should be borne in mind: Hazard Risk anything with the potential to cause harm the likelihood of that harm being realized 3.5 All assessments should follow the five stages identified below (Health and Safety Executive s Five Steps to Risk Assessment ): identify the hazards decide who may be harmed and how Review Date: July 2013 Please ensure you have the latest version of this document 6 of 22

7 evaluate the risks and decide whether existing precautions are adequate or more should be done record the findings review and revise as necessary. 3.6 Training in risk assessment will be available to all staff engaged in the process and given by the Health and Safety Advisors/Risk Co-ordinators. Advice upon specific topic areas is available from those mentioned in Appendix B of this document. 4.0 Risk Rating 4.1 All risks identified via the assessment process must be given a rating according to the matrix given below. Most likely consequence Likelihood of Insignificant Minor Moderate Major Catastrophic occurrence Almost Significant Significant High High High certain Likely Moderate Significant Significant High High Possible Low Moderate Significant High High Unlikely Low Low Moderate Significant High Rare Low Low Moderate Significant Significant 5.0 Risk Control/Principles of Prevention 5.1 Once assessments have been carried out, clear priorities for action need to be established. Risks attracting a rating of significant or high must be reported to both the Divisional Director and the site Director to ensure they are kept informed. Action plans must be drawn up for significant or high level risks to ensure they are reduced to the lowest practicable level. Aside from action plans, control measures must be established for all risks where these are identified as necessary and must be brought to the attention of all staff affected by them (including contractors staff where these are used). Monitoring must be carried out at local level to ensure control measures are being implemented as required. Examples of controls could be: training, policies, procedures, protective equipment, alarms, contingency plans, checklists etc. 5.2 All risk assessments should be reviewed on a regular basis and at least annually in any case. The higher the risk rating, the more regular the review period; assessments must also be reviewed following introduction of new technology or changes to working practices. Review Date: July 2013 Please ensure you have the latest version of this document 7 of 22

8 6.0 Risk Register 6.1 From the risks identified via the assessment process, a risk register will be compiled, establishing priorities for those risks affecting the whole or a significant part of the organisation. The register will include both clinical and non-clinical risks and form the basis for discussion as to allocation of resources. The register will be discussed at the Risk, the Divisional Governance s and by the Executive Directors. 6.2 Risks may also be identified through group review, individual management concerns, following a significant incident, performance data or legislation 7 The Risk Register Process 7.1 The Risk Register will work at three main levels: Corporate (ie Board level) Executive Director/Division Directorate A schematic representation of the process is attached at Appendix B. The content of these registers may originate from two directions as a top down/bottom up approach is in place. Risks descend from the top by means of objectives and directives to the organisational level of management below. Risks ascend the levels by a system of exception reporting. The owner of the risk register is the person with ultimate responsibility for a defined area of responsibility, however they may elect a custodian of the register who will update it and provide relevant reports. 7.2 Corporate The owner of the Board Risk Register is the Chief Executive who will in associate with the Executive Directors and the Board ensure that strategic risks that would influence the business aspects of managing the organisation are recognised and addressed. These risks may derive from: Recognition of threats to the corporate objectives Risks to the organisation s key investment and change projects Key risks arising from the need to comply with external standards Significant risks escalated from Divisions or Executive Directors Key risks from topic specific assessments The risks identified would not only be significant in nature but failure to address these may result in serious consequences for the organisation. The Board will review quarterly a report on corporate risks, collated from key internal risk registers, and shared with Risk at Review Date: July 2013 Please ensure you have the latest version of this document 8 of 22

9 agreed intervals. 7.3 Executive Directors/Divisions The Executive Directors and Divisional Directors will maintain risk registers containing the operational risks for their areas. The Risk Register should be a regular agenda item on the relevant management team meeting for discussion and review. Divisional Directors can escalate risks to the appropriate Executive Director using the criteria for escalation at Appendix C. Risks which do not automatically fall within the remit of one of the Executive Directors or Divisions will, by agreement, be allocated to an Executive Director or Divisional Director to host on their risk register. Review of these registers through the line management and performance management system allows discussion and planning around risks that originate in one Division/Directorate which have the potential to cause risks in other Divisions/Directorates. 7.4 Directorate The Clinical Director will maintain a risk register containing the operational risks for their area. The Directorate Risk Register should be a regular agenda item on the Directorate Team meetings for discussion and review. All risk should be managed at Directorate level unless they fall into the criteria for escalation to the Divisional Register. 8.0 Training and Education 8.1 Risk management training will take place across the Trust and will fall into these categories to cover all employees and contracted staff: Induction - reference to the Trust arrangements for handling risk, essential for all staff. A local induction should be provided for all staff at ward or departmental level. Awareness - general appreciation by all staff of the importance of managing risk and the Trusts strategy for dealing with it. Risk identification and risk reduction programme - techniques for undertaking risk assessment, education and training in incident reporting systems, manual handling training, and all mandatory training requirements. Training and Education - will be carried out in conjunction with the Trust Risk Co-ordinators, Trust Safety Advisors, Trust Manual Handling Coordinators, Trust Fire Officers, Trust Training Department and external agencies. 8.2 The programme will be designed to meet the business plans, local and national recommendations and service needs. Review Date: July 2013 Please ensure you have the latest version of this document 9 of 22

10 9.0 Accident/Incident Reporting 9.1 The Trust will have a system in place to ensure that all accidents, incidents or near misses are reported and recorded at the earliest opportunity and support a positive, non-punitive culture to ensure robust reporting. 9.2 Whilst this is a reactive mechanism for identifying risk, the Trust will investigate accidents/incidents to establish underlying causes and learn any lessons emerging from such investigations. Information from the accident/incident reporting process will feed into the risk identification process to ensure that all risks are identified and enable the Trust to respond accordingly. 9.3 The Trust will work with the NPSA to ensure all Patient Safety Incidents are reported to the National Reporting & Learning System (NRLS. In addition individual incidents will be reported under the STEIS guidance to the Strategic Health Authority and defective equipment to the MHRA. All instances to be reported via the Governance Directorate. In other instances it may be necessary to contact the Police, the coroner, the NRLS or other organisations. The decision to do so should be made in conjunction with the Medical Director or Chief Executive. 9.4 The Trust will also comply with the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR). This requires employers to report certain specified notifiable incidents to the Health and Safety Executive. These include major injuries, specified diseases and specified dangerous occurrences as well as all accidents resulting in absence from work or inability to perform normal duties for more than three days. Details of RIDDOR specified incidents will be available within each Ward or Department to ensure accurate reporting. All RIDDOR reports will be made by the Health and Safety Advisor Performance Monitoring and 10.1 The Trust will actively participate in external assessments and accreditation in order not only to demonstrate compliance with standards but as a way of monitoring its performance and progress with the management of risk. These will include: Care Quality Commission Registration Risk Standards Patient Environmental Assessment Teams (PEAT) Standards Medicines & Healthcare Products Regulatory Agency (MHRA) National Patient Safety Agency (NPSA) External Audit 10.2 Internally, performance management will take place through the line management structure as outlined in the schematic diagram attached at Review Date: July 2013 Please ensure you have the latest version of this document 10 of 22

11 Appendix B. The Board Risk Register will be reviewed quarterly at the Executive Team prior to being submitted to the Trust Board. Individual Executive Director Risk Registers will be reviewed quarterly by the Executive Team. Divisional Risk Registers will be reviewed six monthly as part of the performance review process with the Executive Team. Directorate Risk Registers will be reviewed by Divisional Teams The application of this policy will be monitored by audit against the minimum requirements of the current NHSLA Risk Standards for Acute Trusts, Primary Care Trusts and Independent Sector Providers of NHS Care, Criterion 1.1 Risk Strategy. A monitoring table is attached at Appendix E Provision of Information 11.1 In order to ensure success and ownership of this policy, information must be disseminated to all employees. Copies of policies, procedures and risk assessments should be kept within all wards and departments and drawn to the attention of all staff. Policies and procedures will also be available on the Trust intranet Assessments carried out under the Control of Substances Hazardous to Health Regulations (COSHH) should be carried out using the safety data sheet for the substance in question. Copies of all data sheets should be kept in a file within the Ward or Department alongside the assessments themselves. As with general risk assessments, these should be brought to the attention of all staff prior to their using the substance in question. Training in correct use must be given if required Notices from the Medicines & Healthcare Products Regulatory Agency (MHRA) will be distributed throughout the Trust to staff affected by them. The Trust will have a proactive procedure in place to ensure prompt distribution of all MHRA notices and for feedback from managers to confirm necessary action has been taken References NHS Executive EL (93) 111 Risk in the NHS HSC of Health and Safety in the NHS Trust Risk Strategy of Health and Safety at Work Regulations 1999 NHSLA Risk Standards for Acute Trusts, Primary Care Trusts and Independent Sector Providers of NHS Care Review Date: July 2013 Please ensure you have the latest version of this document 11 of 22

12 13.0 Appendices 13.1 The following appendices have been attached overleaf to support this document: Appendix A Risk Assessment Form Appendix B Schematic Representation Appendix C Criteria for Escalation Appendix D Trust Contacts Appendix E Monitoring Compliance Review Date: July 2013 Please ensure you have the latest version of this document 12 of 22

13 Appendix A Risk Assessment Form THE PENNINE ACUTE HOSPITALS NHS TRUST RISK ASSESSMENT FORM DIVISION/DEPARTMENT: DATE: REVIEW DATE: RISK: LIKELIHOOD: CONSEQUENCE: RISK RATING: CONTROLS IN PLACE: CONTROL EFFECTIVENESS: RESIDUAL RISK RATING: ACTIONS: If the residual risk is HIGH or SIGNIFICANT the action plan overleaf must be completed. The action plan should include interim actions already taken or proposed to reduce the risk; whilst working towards implementation and/or funding of the ultimate action plan to remove the risk or reduce it to an acceptable level. SIGNED: NAME: DESIGNATION: Review Date: July 2013 Please ensure you have the latest version of this document 13 of 22

14 RISK REMOVAL/REDUCTION ACTION PLAN Action No. Description of Action * Priority* * Responsibility*** Cost**** Due Date Date Completed * Description of actions should include interim actions already taken as well as those planned that will reduce the risk prior to the final action identified. ** Priority should be HIGH, MEDIUM or LOW. *** Responsibility is the individual, group or management team responsible for the action. **** Cost should be the estimated total cost of implementing the identified action Dates should be realistic and achievable; where interim actions have already been taken then the date they were implemented should also be included in the Date Completed column. Review Date: July 2013 Please ensure you have the latest version of this document 14 of 22

15 Pennine Acute Hospitals NHS Trust Risk Policy Version 6 Identified Risk The Pennine Acute Hospitals NHS Trust Guidance on the Completion of Risk Assessment Forms This column should describe the identified risk. The risk may affect the Trust, Hospital, Directorate, Department or Individuals (singularly or in groups). It may also relate to health and safety, the provision and/or quality of service or care, the finances of the Trust or it s reputation. The Trust is a very diverse and complex organisation with a wide range of risks; the most significant and threatening risks should be addressed first. Likelihood Likelihood refers to how the Trust/Hospital/Directorate/Department/Individual may be exposed to the identified risk. The options are: - Likelihood Almost certain Likely Possible Unlikely Rare Description Likely to reoccur on many occasions, a persistent issue Will probably reoccur but is not a persistent issue May reoccur occasionally Do not expect it to happen again but it is possible Can t believe that this will happen again Consequence Consequence refers to the effect if the identified risk occurs. The options are: - Catastrophic Major Moderate Minor Insignificant The following table gives examples of these consequences in relation to Personal Injury, Organisational Impact, Financial Loss and Increased Waiting Lists.

16 Pennine Acute Hospitals NHS Trust Risk Policy Version 6 Impact Definitions Description Negligible Minor Moderate Major Extreme Patient Experience Objectives/ Project Injury: physical and psychological Complaints/ Claims Service/ Business Interruption Staffing and Competence Financial; including damage/loss/ fraud Inspection/ Audit Adverse Publicity/ Reputation Reduced quality of Patient experience/ Clinical outcome not directly related to delivery of clinical care Barely noticeable reduction in scope quality or schedule Adverse event leading to minor injury not requiring first aid Locally resolved verbal complaint Interruption in a service which does not impact on the delivery of patient care or the ability to continue to provide service Short term low staffing level temporarily reduces service quality (< 1 day) Short term low staffing level (>1day), where there is not disruption to patient care Negligible organisation/ personal financial loss ( <1K). (NB Please adjust for context) Small number of recommendations which focus on minor quality improvement issues Rumours, no media coverage Little effect on staff morale Unsatisfactory patient experience. Clinical outcome directly related to care provision readily resolvable Minor reduction in scope, quality or schedule Minor injury or illness, first aid treatment required Justified written complaint peripheral to clinical care Short term disruption to service with minor impact on patient care Ongoing low staffing level reduces service quality. Minor error due to ineffective training/implementation of training Minor organisation/ personal financial loss ( 1010K) Recommendations made which can be addressed by low level of management action Low media coverage short term. Some public embarrassment. Minor effect on staff morale/public attitudes Unsatisfactory patient experience/clinical outcome; short term effects expect recovery <1wk. Reduction in scope or quality of project; project objectives or schedule Agency reportable, eg Police (violent and aggressive acts). Significant injury requiring medical treatment and/or counselling Below excess claim Justified complaint involving lack of appropriate care Some disruption in service with unacceptable impact on patient care Temporary loss of ability to provide service Late delivery of key objective/service due to lack of staff. Moderate error due to ineffective training/implementation of training. Ongoing problems with staffing levels Significant organisational/personal financial loss ( K) Challenging recommendations that can be addressed with appropriate action plan Local media long term adverse publicity. Significant effect on staff morale and public perception of the organisation Unsatisfactory patient experience/clinical outcome; long term effects expect recovery >1wk. Significant project over-run Major injuries/long term incapacity or disability (loss of limb) requiring medical treatment and/or counselling Claim above excess level Multiple justified complaints Sustained loss of service which has serious impact on delivery of patient care resulting in major contingency plans being invoked Uncertain delivery of key objective/service due to lack of staff. Major error due to ineffective training/implementation of training Major organisational/ personal financial loss (100K-1m) Enforced action Low rating Critical report National media/adverse publicity, less than 3 days. Public confidence in the organisation undermined. Use of services affected Unsatisfactory patient experience/clinical outcome; continued ongoing long term effects Inability to meet project objectives; reputation of the organisation seriously damaged Incident leading to death or major permanent incapacity Multiple claims or single major claim Complex justified complaint Permanent loss of core service or facility Disruption to facility leading to significant knock on effect Non delivery of key objective/service due to lack of staff Loss of key staff Critical error due to ineffective training/ implementation of training Severe organisation/ personal financial loss ( >1m) Prosecution Zero rating Severely critical report National/international medial/adverse publicity, more than 3 days MSP/MP concern (Questions in Parliament) Court Enforcement Public Inquiry/FAI

17 Pennine Acute Hospitals NHS Trust Risk Policy Version 6 Risk Rating The inherent risk rating is obtained by using the comparison of likelihood and consequence in the table below. The rating will be High, Significant, Moderate or Low. Consequences Insignificant Minor Moderate Major Catastrophic Likelihood Almost Certain Significant Significant High High High Likely Moderate Significant Significant High High Possible Low Moderate Significant High High Unlikely Low Low Moderate Significant High Rare Low Low Moderate Significant Significant Controls in Place This column should identify and describe the control measures currently in place in relation to the identified risk. Control Effectiveness In this column a judgement must be made on the effectiveness of the control measures in place. They should be judged on their effectiveness at controlling the identified risk. The ratings are Satisfactory, Some Weaknesses and Weak. Satisfactory: Controls are strong, operating properly and provide a reasonable level of assurance that the risk is adequately controlled. Some Weaknesses: Some control weaknesses/inefficiencies have been identified. Although not considered to present a serious risk, improvements are required to provide reasonable assurance that the desired level of quality is attained. Weak: Controls do not meet an acceptable standard and do not provide assurance that the identified risk is adequately controlled. Residual Risk Rating This column identifies the residual risk after taking into account the existing control measures. The options are High, Significant, Moderate or Low and are calculated using the table below which compares Risk Rating and Control Effectiveness. Control Risk Rating Effectiveness Low Moderate Significant High Weak Moderate Significant High High Some Weaknesses Low Moderate Significant High Satisfactory Low Low Moderate Significant Action Required/Comments This column should identify necessary action required to remove or reduce to an acceptable level the identified risk, if not already adequately controlled. The column should always be completed when the residual risk is identified as high or significant.

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19 Pennine Acute Hospitals NHS Trust Risk Policy Version 6 Appendix C Criteria for Escalation Issues to consider if planning escalating a risk 1 The issue is currently on the appropriate Risk Register Yes/No 2 The issue has been scored and has been assessed as a very high risk Yes/No 3 All possible controls have been implemented Yes/No 4 Other sources of funding available have been considered Yes/No 5 The Team believes there is no provision in the current budget Yes/No to address this risk 6 The Team believes this risk needs to be addressed and are Yes/No able to demonstrate the reduction of risk from any additional finance made available If No to any question the risk requires to be explored further at the current management level to ensure it is a true exception If all Yes, pass to more senior management level It is preferable that several options of risk reduction should be presented to the more senior level providing a range of choice Issues to be considered when receiving escalated risks Criteria to be used to assess the risk 1 Is there agreement on the scoring of the risk? (Likelihood x Severity) Yes/No 2 What evidence does the submitting manager have to justify the Likelihood score of the risk? (Audit, incident report, claim, complaints, Inspection, external review) Evidence Available No Evidence Available 3 Is there agreement that the Directorate/Division does not have Funding within the budget for this issue? 4 Have other controls and solutions been implemented in other Services which could be applied as an alternative to additional Funding? 5 Are there any knock-on effects/impact on any of the other areas? 6 Are there other alternative controls that could be implemented? Yes/No Yes/No 7 Is further information required before making a decision? After due consideration of actions to be taken, feedback must be provided to the Service/Directorate/Division who escalated the risk

20 Appendix D - Trust Contact Numbers Fairfield Site TRUST CONTACT NUMBERS NAME ROLE NUMBERS Diane Panter Risk Co-ordinator Kevin Kennerdale Health & Safety Advisor Deborah Pullen Head of Claims David Smith Fire Advisor Sylvia Maxfield Infection Control Nurse Clare Shepherd Clinical Audit Co-ordinator Julia Grant PALS Officer Susan Hill PALS Officer Dr R Burman Consultant Microbiologist Lisa Bowe Moving & Handling Co-ordinator Beverley Sedman Blood Transfusion Practitioner Rochdale Site NAME ROLE NUMBERS Marjorie Gabbott Risk Co-ordinator Kevin Kennerdale Health and Safety Advisor Deborah Pullen Head of Claims David Smith Fire Advisor Ann Taylor Infection Control Nurse Shirley Naylor Clinical Audit Co-ordinator Angela Greenwood PALS Officer Dr I Cartmill Consultant Microbiologist Patricia Barbagiannis Moving & Handling Co-ordinator Beverley Sedman Blood Transfusion Practitioner North Manchester Site NAME ROLE NUMBERS Arlene Ryan Risk Co-ordinator Jane Sutcliffe Health and Safety Advisor Deborah Pullen Head of Claims Eric Rosenberg Fire Advisor Mike Beesley Roz Kaufman Infection Control Nurses Bleep 4235 Claire Shepherd Clinical Audit Co-ordinator Julia Grant PALS Officer Susan Hill PALS Officer Dr Hari Panigrahi Consultant Microbiologist Richard Olver o Moving & Handling Co-ordinator Wendy Clapham Blood Transfusion Practitioner Review Date: June 2010 Please ensure you have the latest version of this document 20 of 22

21 Oldham Site NAME ROLE NUMBERS Diane Grubb Risk Co-ordinator Stephanie Mills Health and Safety Advisor Deborah Pullen Head of Claims Graham Brooks Fire Advisor Claire Chadwick Infection Prevention Consultant Lorraine Durham Infection Control Nurse Elizabeth Wilson Infection Control Nurse Shirley Naylor Clinical Audit Co-ordinator Angela Greenwood PALS Officer Dr I Cartmill Consultant Microbiologist Val Green Moving & Handling Co-ordinator Susan Andrews Blood Transfusion Practitioner Complaints based at North Manchester General Hospital NAME ROLE NUMBERS Sonia Appleton Head of Complaints/PALS Gillian Armstrong Complaints Manager Amanda Barnes Complaints Manager Zaheer Patel Complaints Manager Review Date: June 2010 Please ensure you have the latest version of this document 21 of 22

22 Pennine Acute Hospitals NHS Trust Risk Policy Version 6 Appendix E Arrangements for Monitoring Compliance with this Policy The arrangements for monitoring compliance of this policy in relation to the NHSLA minimum standards are summarised in the following table: Minimum requirement to be monitored Process for Monitoring Responsible Individual/ Group/ for Monitoring Frequency of Monitoring Responsible Individual/Group / for Development of Action Plan Accountability/responsibilities Review process Internal Audit Annual Risk Risk assessment process Review process Internal Audit Annual Risk Risk register process Review process Internal Audit Annual Risk of risk locally Review process Internal Audit Annual Risk Duties Review process Internal Audit Annual Risk Actions Review process Internal Audit Annual Risk Responsible Individual/Group. for Development of Action Plan Governance Director Governance Director Governance Director Governance Director Governance Director Governance Director Responsible Individual/Group/ for Monitoring of Action Plan Risk Risk Risk Risk Risk Risk