Risk Management Policy

Transcription

1 Risk Management Policy Originator: Barbara Gale Chief Executive Review date: April 2015 Revision date: April 2017 Approved by: Finance & Investment Committee Date of meeting: 22 April 2015 Name of Chair: David Barclay Approved by: Board of Trustees Date of meeting: 21 May 2015 Name of Chair: Adrian Williams

2 Contents 1. Policy Statement 3 2. Introduction Definition 4 3. Responsibilities and Accountability Chief Executive Officer (CEO) Directors Managers Employees and volunteers 5 4. Procedures and Implementation Risk Assessment Risk Analysis Education and training Meetings 6 5. Related Policies / Guidelines 6 6. Monitoring and Review 6 7. Statutory Compliance and evidence referenced 6 8. Appendices 6 Page 2 of 6

3 1. Policy Statement St Nicholas Hospice Care will ensure consistent risk management techniques are in place across the organisation. Managing risk is a key organisational responsibility and is seen as an integral part of the management and governance processes. Effective risk management is achieved by ensuring the whole workforce is engaged with managing and mitigating risk. St Nicholas Hospice Care is committed to ensuring that risk management forms an integral part of its philosophy, practices and development plans and that responsibility for implementation is accepted at all levels of the organisation. This is best achieved through an environment of honesty and openness where mistakes and adverse events are identified quickly and dealt with in a positive and responsible manner. St Nicholas Hospice Care recognises that it is not possible to eliminate risk, but aims to try and minimise the risk where possible. St Nicholas Hospice Care is an independent charity delivering specialist palliative care to patients and their families within the communities of West Suffolk and Thetford. Care is delivered by a specially trained multidisciplinary team supported by a large team of volunteers to patients within our Sylvan Ward, Community Hospice Team, Orchard and Burton Centres. The organisation also includes an Education Department that delivers palliative care education to the local community, a Fundraising Department that manages a range of fundraising activities and a Retail Section with several shops in the local community staffed by paid staff and volunteers. 2. Introduction St Nicholas Hospice Care takes an integrated approach to risk across the organisation embracing financial, organisational, corporate and clinical risks. Risk management programmes are directed towards the prevention of loss/harm and the limitation of damage when loss/harm has occurred. This policy applies equally to all members of staff, either permanent or temporary and to those working within, or for, St Nicholas Hospice Care under a contract for services volunteers students and learners on placement. The policy outlines how risk is managed, organised and put into practice by St Nicholas Hospice Care. All staff has responsibility for risk management; some have more responsibility than others. This Policy was developed in consultation with Directors and the Management Team. The risk management arrangements shall ensure that: There are effective and efficient arrangements for the identification, assessment and management of risk. The standards of clinical and corporate governance ensure accountability for delivery of high quality, cost effective services. The activities associated with risk management support the delivery of the strategic challenges and corporate objectives defined within the St Nicholas Hospice Care Operational and Strategic Plans. St Nicholas Hospice Care shall be proactive in identifying all potential risks, analysing and managing the risk. Page 3 of 6

4 Good communications exist within St Nicholas Hospice Care to ensure that policy, procedure and effective practice is adopted across the organisation. A log of all risk assessments is held on a risk register to meet the requirements of good governance. 2.1 Definition Policy - Your statement of intent, what you intend to do. Employees must follow/do what is in the policy. Hazard A hazard is something which has the potential to cause injury, illness or harm, for example: Risk Risk is the likelihood that harm or damage may occur and the consequence /severity of the outcome. Risk Assessment Risk assessment is a careful examination of what, could cause harm - so that you can weigh up whether you have taken enough precautions or should do more. Consequence the outcome or impact of an event. Likelihood used as a general description of probability. 3. Responsibilities and Accountability 3.1 Chief Executive Officer (CEO) The Chief Executive has ultimate responsibility for implementation of this policy. The CEO will ensure that this policy is approved by the Board of Trustees. The Chief Executive has overall responsibility for Risk Management within St Nicholas Hospice Care. The Chief Executive accepts responsibility through the implementation of this policy for all aspects of controls assurance and risk management. Together with the CEO the Directors are responsible for developing and implementing risk management plans that support St Nicholas Hospice Care Risk Management Policy. 3.2 Directors Each Director is responsible for risk management in their own area and will ensure that appropriate and effective risk management processes are in place within their designated area(s) and scope of responsibility; and that all staff, students and volunteers are made aware of the risks within their work environment and of their personal responsibilities. (See Appendix 1 for organisational chart). In situations where significant risks have been identified and where local control measures are considered to be potentially inadequate, directors are responsible for bringing these risks to the attention of the CEO. Risk Management is an integral part of the operational planning and managers will be required to identify and record the main risks for their plan together with key actions to reduce the risk. Page 4 of 6

5 3.3 Managers All managers have the same responsibilities as staff generally, for risk management in addition managers have the following responsibilities: To ensure staff, students and volunteers understand the risks within their department / place(s) of work To report all risk for which they are unable to take action to an appropriate Director. To investigate all risks that are reported to them by staff and where appropriate complete risk assessment forms. To ensure that all staff are aware of St Nicholas Hospice Care policies and procedures that relate to risk management and their department or the areas in which they work. 3.4 Employees and volunteers All Hospice staff (paid staff and volunteers) plays an important role in the management of risk by monitoring, reviewing and evaluating the many aspects of services in order to maintain compliance with acceptable standards. All staff will be personally responsible for complying with the policy and associated strategies, policies and procedures. All staff are responsible for ensuring that they: - Do nothing to create a risk Do not make an existing risk worse Report risks that they become aware of. Co-operate with St Nicholas Hospice Care on arrangements to minimise risks. 4. Procedures and Implementation 4.1 Risk Assessment Risk Assessment will be carried out by all services/departments to identify the significant risks arising out of all St Nicholas Hospice Care activities (environment, financial, health & safety, clinical) and assess their potential to cause injury, result in litigation, cause damage to the environment or property, result in delays or loss of reputation. These assessments will be the basis of prioritising risk (and in turn the services, procedures and so on). High risk issues will be given paramount importance Risks will be recorded centrally on the Risk Register, found on the S drive. 4.2 Risk Analysis St Nicholas Hospice Care uses the same 5x5 matrix technique from the AS/NZS Risk Management Standard, for both proactive risk assessments and reactive adverse incident forms. Use of the matrix enables a list of prioritised risks to be developed with an indication of the action that may be required and highlights the most significant risk issues to be considered by the Directorate and subsequently the St Nicholas Hospice Care Board of Trustees. (See Appendix 2) 4.3 Education and training Education and training at all levels is an essential element of Risk Management. There are mandatory induction programmes which include risk management. CEO, Directors, managers and staff will be appropriately trained and skilled in risk management and carrying out risk assessment. Page 5 of 6

6 Raising the general awareness of staff will also be undertaken through staff briefings, induction programme and within internal communications. 4.4 Meetings Risk management will be discussed monthly at the Directorate meeting and is a standing agenda item at the monthly Operational Managers Meeting. Risk management form part of the report made by the CEO to the Board of Trustees every 3 months. Risk management is a standing agenda item on the Board of Trustees sub-committees. 5. Related Policies / Guidelines Health and Safety Policy. Complaints Policy. 6. Monitoring and Review The Directors and CEO will use a variety of measures and indicators to monitor the effectiveness of this policy. This policy will be reviewed annually and amended as necessary to ensure that it still reflects our activities, current legislation and healthcare best practice. 7. Statutory Compliance and evidence referenced Care Standards Act Health Act 2006 Care Quality Commission Charity Commission AS/NZS Risk Management Standard 8. Appendices These can be found within the St Nicholas Hospice Care S: \ Drive. Appendix 1 Management Structure Appendix 2 Risk Matrix Appendix 3 General Risk Assessment Template (new) Page 6 of 6