Policy & Guidance for Risk Assessment & Risk Registers - the Royal ...

• Undertaking and participating in training as required• Implementing and adhering to the identified control measures to minimise therisks identified within the assessment• Raising concerns about any activity, practice or location that does not appear tohave a satisfactory risk assessment.• Seeking assistance with any aspect of the task when uncertain of the actions tobe taken.• Actively participating in training in relation to the application of this document.6. Standards and Practice6.1. Risk Assessment6.1.1. The risk assessments process is fundamental in ensuring both anenvironment that is safe for staff and patients and facilitating effective andproductive working practices.6.1.2. There are a number of specific risk assessment types that aredesigned for different activities; these include, but are not restricted to,Generic Health and Safety risks, lifting and carrying risks, DSE/work station(computer), hazardous substances, plant & equipment, patient falls andwork at height assessments. Additional assessments are also required forcertain groups of staff including new and expectant mothers, disabledpersons, young people and staff working during the night.6.1.3. The Trust’s specialist advisors will provide guidance oncompleting and the relevant types of risk assessments.6.1.4. Risk assessments will be carried out for all roles and activitiescarried out by or for the Trust. Risk assessments will be carried out bytrained staff from within the department and include consultation withrepresentatives of the area/activity. Risk assessments will be documentedusing the appropriate risk assessment template6.1.5. Once the risk assessment is completed it will be shared with allrelevant staff in the area and any additional controls required implementedwithin the given time frame. The risk assessment details will be added tothe departmental risk register and, where appropriate, the directorate andTrust registers6.1.6. All risk assessments will be reviewed by the appropriate manageron an annual basis or more frequently if the circumstances change – i.e. achange in working practices, new equipment introduced, physical change inwork area or layout.6.1.7. Risk assessments will be reviewed within the Trust’s internal andexternal audit procedures including audits by the Health and Safety Team.6.1.8. Risk assessments should be held within the Datix system andused to compile the Risk Registers. Datix risk entries will be supplementedwith additional information and evidence detailing the controls and actionstaken. Complex entries will also include breakdown of assessments usingthe Trust Risk Assessment Templates.Policy and Guidance for Risk Assessment and Risk RegistersPage 5 of 21

6.2. Risk Assessment Process6.2.1. The risk assessment process for all types of risk will follow thesame basic procedure, identification of the hazards, likelihood of risk, whois at risk, existing controls and review. A flow chart for the risk assessmentprocess is provided below. Generic guidance on completing the riskassessment process is provided in Appendix 1.6.3. Risk Assessment Process flow chartIdentify theHAZARDAnything (physical orprocess) with thePOTENTIAL to causeHARM to persons orpropertyIdentify theRISKThe LIKELIHOOD of theharm from the HAZARDbeing realisedIdentify WHOMay beHARMEDStaffPatientsVisitorsContractorsProperty/Equipment, Etc.Identify theCONTROLSExisting andRequiredHow is the risk managedat the moment? –including: physicalcontrols, process andsystems of work, training,etc.Are additional controlsrequired?REVIEWEstablish a plannedreview period (usuallyannual) but prepare toundertake review of theassessment in the eventof any significant changein the activity i.e. changein personnel, equipment,software, incidents.Policy and Guidance for Risk Assessment and Risk RegistersPage 6 of 21

6.4. Flowchart for escalation of RisksRisk IdentifiedCan the risk beManaged Locally?YesNoEscalate tospecialty orDepartmentManagementReview & MonitorCan the risk bemanaged withinSpeciality/Department?YesReview &MonitorNoEscalate toDivisional LevelReview &MonitorYesCan the risk bemanaged within theDivision?NoReturn toDivisional levelfor review of riskrating &managementNoYesLegendEscalate RiskManage at levelReview &MonitorSubmit to RiskCommittee forconsideration toCorporate RiskRegisterReview &MonitorReturn toDivisional levelfor review of riskrating &managementMonitor & Reviewrisk regularlyDe-escalate andreview risk ratingYesAccept on CorporateRisk Register forreview andconsideration by theTrust BoardNoPolicy and Guidance for Risk Assessment and Risk RegistersPage 7 of 21

6.5. Risk Register6.5.1. The Trust Risk Registers are formulated from the entriescontained within the Trust’s electronic risk management system.6.5.2. Risk Registers will be complied from risk assessments undertakenfor tasks, activities, roles and physical areas within the Trust’s areas ofresponsibility.6.5.3. Significant risks and risks with the potential to affect more thanone area or directorate will be will be considered by the risk Committee foraddition to the Trust register.6.5.4. All proposed entries to the Corporate Risk Register will besubmitted from the Risk Committee to the Trust Board for final approvaland inclusion in the register.6.5.5. Divisional risk registers will, typically, record risks with a score inexcess of 12; all such risks will be reviewed quarterly by the Head of theDivisional6.5.6. Divisions of large size or with a complex structure may alsoestablish sub registers and committee(s) to monitor and review specialistrisks.6.5.7. Risk assessments will also be reviewed in the event of asignificant change in the working practices, procedures, systems andpersonnel. Furthermore, assessments will be reviewed and revised asappropriate in the event of a significant accident or incident or in the eventthat a trend or pattern of minor incidents is identified in a particular area.6.5.8. General risk assessments will be reviewed on a sample basis aspart of the periodic health and safety audits of divisions/areas/departmentsby the Trust Health and Safety Team.6.5.9. The Flowchart for escalation of Risks is provided above6.6. Training6.6.1. General awareness of the process of risk assessment will be includedin within the existing Trust induction training. Staff who are nominated toundertake risk assessments within divisions and areas will receive training inthe completion of risk assessments.6.6.2. Managers are responsible for ensuring that assessments arecompleted, are suitable and sufficient and for reviewing assessments willhave training incorporated into the manager’s health and safety training.6.6.3. Additional risk assessment training will be provided as required inaccordance with the Trust Core Training Needs Policy.Policy and Guidance for Risk Assessment and Risk RegistersPage 8 of 21

6.6.4. The provision and arrangements for risk assessment training will bereviewed and revised as necessary.7. Dissemination and Implementation7.1. This document will be published on the RCHT Intranet site and available to allTrust staff. Where appropriate additional paper copies will be made available topersonnel without ready access to the intranet.7.2. Once the document is finally approved electronic copies will be held within theelectronic Documents Library (DL2) and a link to the document provided within the“Daily bulletin” all user email.7.3. The final document will also be distributed to both the staff and managementrepresentatives of the Health and Safety Committee to ensure all divisions are awareof the requirements.7.4. The Trust arrangements for the risk assessment process, as defined in thisdocument, will be highlighted during Trust induction and mandatory training.7.5. The policy may also be provided to contractors and other third partiesundertaking work or activities for or on behalf of the Trust or on Trust premises.8. Monitoring compliance and effectivenessElement to bemonitoredThe undertaking, monitoring and reviewing of risk assessments andmanagement of risks within the day-to-day activities of the organisation.LeadThe Chair of the Trust Risk CommitteeToolReports created from the Datix Risk Management and reported to themonthly Divisional Governance meetings with higher level and organisationalrisks being reviewed by the Risk Committee.Significant health and safety risks may also be reported to the Trust Healthand Safety CommitteeFrequency Divisional Governance Committee Report Monthly Risk Committee - Monthly Health & Safety Committee – QuarterlyAs part of the scheduled health and safety audits a sample ofapproximately 10 Risk Assessments from across the Trust will bereviewed each month.In addition a periodic review of the “Health and Safety Self Audit Tool”returns will be reviewed and trends identified at local, divisional and Trustwide levels; these results will also feed into the PAF (from mid 2012)ReportingarrangementsDivisional Governance meetings will monitor the risk assessments for thedivision, including ensuring that local assessments are completed andreviewed.The Risk Committee will review all risks escalated to the Trust Risk Register(usually with a rating in excess of 15 but also lower level risks that may affectmore than one area/department. Risks not accepted on the Trust RiskRegister will be returned to the Division for review, further evidence or localmanagement as appropriate. Trust Risk Register entries will be reviewed bythe Trust Board at intervals not exceeding 12 calendar monthsPolicy and Guidance for Risk Assessment and Risk RegistersPage 9 of 21

Acting onrecommendations andLead(s)Change inpractice andlessons to besharedThe Health and Safety Committee will review all significant health and safetyrisks as reported through the biennial divisional reports.Divisional Risks Are Reported To The Divisional Governance CommitteeAnd A Further Report Requested.Health And Safety Risks Will Be Discussed By the Health And SafetyCommittee and feedback to the division or department will be cascaded bythe Divisional Safety Representatives and via the minutes of the meetings..Required changes to practice will be identified and actioned within the timeframe agreed at the appropriate committee depending on the level of riskidentified. A lead member of the relevant division, area or group will beidentified to take each change forward where appropriate. Lessons will beshared with all the relevant stakeholders9. Updating and Review9.1. This document will be reviewed by the Trust Health and Safety Advisors withstaff consultation via the Health and Safety Committee prior to Trust approval andimplementation by the Governance Committee. The document will be subject to abiennial review cycle commencing in December 2012.9.2. In the event of a significant change in associated legislation or in the event of asignificant change in organisational structure or practices the document reviewmaybe brought forward.9.3. Minor revisions, such as, amended job titles or changes in the organisationalstructure, approval can be sought from the Executive Director responsible forsignatory approval, and can be re-published accordingly without having gone throughthe full consultation and ratification process.9.4. Any revision activity is to be recorded in the Version Control Table as part of thedocument control process.10. Equality and Diversity10.1. This document complies with the Royal Cornwall Hospitals NHS Trust serviceEquality and Diversity statement.10.2. Equality Impact AssessmentThe Initial Equality Impact Assessment Screening Form is at Appendix 2.Policy and Guidance for Risk Assessment and Risk RegistersPage 10 of 21

Appendix 1. Generic Risk Assessment Guidance1. The requirement to undertake suitable and sufficient assessments of the risks arisingfrom work activities to the health and safety of employees and of those not employed,stems from regulation 3 of The Management of Health and Safety at Work Regulations1999 as amended.2. Some situations require specific risk assessments to be carried out includingactivities involving manual handling tasks, New and expectant mothers, young people andnight working.3. The Health and Safety Executive have identified 5 steps to carry out a riskassessment: -1. Identify the hazard2. Identify the risk3. Identify who is at risk4. Controls in place5. Additional controls required4. In order to identify a hazard it is necessary to define a few terms:• A HAZARD is any thing or situation that has the potential to cause harm,damage or injury.• The RISK is how likely the harm from the hazard is likely to occur• WHO is at risk – consider the groups of people who maybe affected includingstaff, visitors, contractors and patients – consider the types of patients and anyadditional factors that may change the risk level (i.e. elderly, immunesuppressed, children, visually impaired, etc)• The CONTROL MEASURES are the steps taken to prevent the harm occurring• LIKELIHOOD – how likely is the incident to occur – this is based on history ofincidents both locally and generally associated with this activity/equipment, etc.• SEVERITY – what would be the extent of the injuries or damage caused by thehazard. Consider Injuries, damage, PR, etc5. For example:• The main entrance to an reception is freshly cleaned floor and left wet =HAZARD.• RISKo If the floor is cleaned at 4 a.m. when the building is closed the RISK is verylow; = Lowo RISK. However, if the wet floor is cleaned at 8.30 in the morning, with all thestaff and patients coming in the RISK will be High.• Severity of the injury or outcome of the risk will depend upon a number offactors including:The type of person (a minor fall may have very different outcome for a 25year old and an 85 year old!).The area where the incident occursThe time of day, lighting and weather conditionsPolicy and Guidance for Risk Assessment and Risk RegistersPage 11 of 21

6. Although a large employer involved in wide ranging work activities, the majority of theTrust’s work is low or medium risk. To assess the possible impact of its activities the Trustuses a form of semi-quantitative risk assessment. That is to say, it is a largely descriptiveprocess undertaken by individuals familiar with or involved in the activities beingconsidered, together with use of a simple risk matrix to provide a numerical value andindicates whether it is high, medium or low risk.7. The risk matrix uses five possible levels of severity for an outcome and five for thelikelihood of it happening. When these are multiplied together they give a numerical valuefor the risk Value (see table 1). The overall process follows the Health and SafetyExecutive’s 5 Step Process and is explained step by step in the following paragraphs. TheTrust’s workforce is divided up into groups with common job descriptions and roles. Assuch the most convenient way to conduct the process is to undertake assessments basedon the job description or role. If any employees are young and /or relatively inexperienced,women of child bearing age or disabled you must allow for any effect that this may have inthe assessment.8. Managers are expected to undertake or arrange for (by someone who has beentrained) the assessment of risks within their work area. Employees must always beconsulted, either directly or through their elected representatives. Assessments must bereview whenever there is a change to the work or the way it is undertaken or in theabsence of change, at least annually.9. The outcome of the assessment should be recorded within the Datix system, the riskassessment:9.1 The easiest way to begin is to list the work activities of the employeesconcerned and then ask “how could they become injured doing this?” This shouldidentify the hazards – something that has the potential to cause harm. Now identifythe controls you have in place to reduce the likelihood that the hazard will causeharm.9.2 Next estimate the risk of that hazard actually causing harm with your controls inplace. Risk can be thought of as a combination of two things: the likelihood that thehazard will cause harm and the extent of the harm caused. For ease, we suggest anumerical scale for both aspects of the risk, see table below.9.3 Decide how likely it is that the hazard will give rise to harm. This can be doneusing personal experience or evidence for the number of times it has occurred in thepast, i.e., from accident reports, see table 1 for a suggested scale.9.4 Now decide how severe the outcome is likely to be. Again this can be a mixtureof personal experience and evidence drawn from data such as accident reports, seetable 1 for the suggested scale.9.5 Multiply together the two numbers obtained from table 1 (one for likelihood andone for severity) and look-up this value in the risk matrix below table 1. This will giveyou a risk rating which is colour coded as high, medium or low. Enter this result intothe Datix risk assessment “form”, together with the current controls etc.9.6 If the outcome of your assessment is “Low”, you may not need to do anythingfurther, unless there is something obvious that can be done to reduce the likelihoodor possible severity of harm arising from the hazard9.7 Those hazards where the risk is classified as “Medium” need furtherconsideration and you should look for ways to further control the risk of harm fromthe hazard.Policy and Guidance for Risk Assessment and Risk RegistersPage 12 of 21

10. Where the risk from a hazard is classified as “High”, steps must be taken to reducethe risk before work progresses, keep a record of your findings, proposals and timescalefor action to be taken using the fields within Datix. When trying to reduce the risk, thefollowing hierarchical system should be adopted: -• Does the activity need to be undertaken?• Can the objective be achieved in another way?• Can you use different equipment or chemicals?• Would it be safer if more staff were involved?• As a last resort, can personal protective equipment be used?Risk LikelihoodMatrix 1 2 3 4 51 1 2 3 4 52 2 4 6 8 103 3 6 9 12 154 4 8 12 16 205 5 10 15 20 25SeverityPolicy and Guidance for Risk Assessment and Risk RegistersPage 13 of 21

Consequence score (severity levels) and examples of descriptors1 2 3 4 5Domains Negligible Minor Moderate Major CatastrophicImpact on the safetyof patients, staff orpublic(physical/psychological harm)Minimal injuryrequiring no/minimalintervention ortreatment.No time off workMinor injury or illness,requiring minorinterventionRequiring time offwork for >3 daysModerate injuryrequiring professionalinterventionRequiring time offwork for 4-14 daysMajor injury leadingto long-termincapacity/disabilityRequiring time offwork for >14 daysIncident leading todeathMultiple permanentinjuries or irreversiblehealth effectsIncrease in length ofhospital stay by 1-3daysIncrease in length ofhospital stay by 4-15daysIncrease in length ofhospital stay by >15daysAn event whichimpacts on a largenumber of patientsQuality/complaints/auditPeripheral element oftreatment or servicesuboptimalInformalcomplaint/inquiryOverall treatment orservice suboptimalFormal complaint(stage 1)Local resolutionRIDDOR/agencyreportable incidentAn event whichimpacts on a smallnumber of patientsTreatment or servicehas significantlyreducedeffectivenessFormal complaint(stage 2) complaintMismanagement ofpatient care withlong-term effectsNon-compliance withnational standardswith significant risk topatients if unresolvedMultiple complaints/independent reviewTotally unacceptablelevel or quality oftreatment/serviceGross failure ofpatient safety iffindings not acted onHuman resources/organisationaldevelopment/staffing/ competenceShort-term lowstaffing level thattemporarily reducesservice quality (< 1day)Single failure to meetinternal standardsMinor implications forpatient safety ifunresolvedReducedperformance rating ifunresolvedLow staffing level thatreduces the servicequalityLocal resolution (withpotential to go toindependent review)Repeated failure tomeet internalstandardsMajor patient safetyimplications iffindings are not actedonLate delivery of keyobjective/ service dueto lack of staffUnsafe staffing levelor competence (>1day)Low performanceratingCritical reportUncertain delivery ofkey objective/servicedue to lack of staffUnsafe staffing levelor competence (>5days)Inquest/ombudsmaninquiryGross failure to meetnational standardsNon-delivery of keyobjective/service dueto lack of staffOngoing unsafestaffing levels orcompetenceStatutory duty/inspectionsAdverse publicity/reputationNo or minimal impactor breech ofguidance/ statutorydutyRumoursPotential for publicconcernBreech of statutorylegislationReducedperformance rating ifunresolvedLocal mediacoverage –short-term reductionin public confidenceElements of publicexpectation not beingPolicy and Guidance for Risk Assessment and met Risk RegistersLow staff moralePage 14 of 21Poor staff attendancefor mandatory/keytrainingSingle breech instatutory dutyChallenging externalrecommendations/improvement noticeLocal mediacoverage –long-term reduction inpublic confidenceLoss of key staffVery low staff moraleNo staff attendingmandatory/ keytrainingEnforcement actionMultiple breeches instatutory dutyImprovement noticesLow performanceratingCritical reportNational mediacoverage with 3days service wellbelow reasonablepublic expectation.MP concerned(questions in theHouse)Total loss of publicconfidence

Businessobjectives/ projectsFinance includingclaimsService/businessinterruptionEnvironmentalimpactAdditionalGuidance onImpact on the safetyof patients, staff orpublic(physical/psychological harm)Insignificant costincrease/ scheduleslippageUnder £300k orloss of 0.01 per centof budgetSmall lossRisk of claim remoteLoss/interruption of>1 hourMinimal or no impacton the environmentIncorrect medicationdispensed but nottakenIncident resulting in abruise/grazeDelay in routinetransport for patient8 hoursMinor impact onenvironmentWrong drug ordosage administeredwith no adverseeffectsPhysical attack suchas pushing, shovingor pinching, causingminor injurySelf-harm resulting inminor injuriesGrade 1 pressureulcerLaceration, sprain,anxiety requiringoccupational healthcounselling (no timeoff work required)5–10 per cent overproject budgetSchedule slippageUp to £1.5m orloss of 0.05 per centof budgetClaim(s) between£10,000 and£100,000Loss/interruption of>1 dayModerate impact onenvironmentWrong drug ordosage administeredwith potential adverseeffects.Physical attackcausing moderateinjurySelf harm requiringmedical attentionGrade 2/3 pressureulcerHealthcare-acquiredinfection (HCAI)Incorrect orinadequateinformation/communication on transfer ofcareVehicle carryingpatient involved in aroad traffic accidentSlip/fall resulting ininjury such as asprainNon-compliance withnational 10–25 percent over projectbudgetSchedule slippageKey objectives notmetUncertain delivery ofkey objectiveUp to £3m or loss of0.1 per cent ofbudgetClaim(s) between£100,000 and £1millionPurchasers failing topay on timeLoss/interruption of>1 weekMajor impact onenvironmentWrong drug ordosage administeredwith adverse effectsPhysical attackresulting in seriousinjuryGrade 4 pressureulcerLong-term HCAIRetainedinstruments/materialafter surgeryrequiring furtherinterventionHaemolytictransfusion reactionSlip/fall resulting ininjury such asdislocation/fracture/blow to the headLoss of a limbPost-traumatic stressdisorderFailure to follow upand administervaccine to baby bornto a mother withhepatitis BIncident leading >25per cent over projectbudgetSchedule slippageKey objectives notmetNon-delivery of keyobjectiveAbove £3m or loss of>1 per cent of budgetFailure to meetspecification/slippageLoss of contract /payment by resultsClaim(s) >£1 millionPermanent loss ofservice or facilityCatastrophic impacton environmentUnexpected deathSuicide of a patientknown to the servicein past 12 monthsHomicide committedby a mental healthpatientLarge-scale cervicalscreening errorsRemoval of wrongbody part leading todeath or permanentincapacityIncident leading toparalysisIncident leading tolong-term mentalhealth problemRape/serious sexualassaultPolicy and Guidance for Risk Assessment and Risk RegistersPage 15 of 21

Likelihood score 1 2 3 4 5Descriptor Rare Unlikely Possible Likely Almost certainFrequencyHow often mightit/does it happenThis will probablynever happen/recurDo not expect it tohappen/recur but itis possible it may dosoMight happen or recuroccasionallyWill probablyhappen/recur but it isnot a persisting issueWill undoubtedlyhappen/recur,possibly frequently11. Where the risk is considered “Extreme” the activity should be suspended and urgentassistance and advice should be sought in reviewing the control measures in place orrequired.12. Additional assistance should be sought from the specialist service for the area of therisk (i.e. health and safety advisors for health & safety risks, Fire Advisors for fire relatedrisks, IPAC for infection control risks, etc).Policy and Guidance for Risk Assessment and Risk RegistersPage 16 of 21

Appendix 2. Governance InformationDocument TitleDate Issued/Approved: 28 Jun 13Policy & Guidance for Risk Assessment &Risk RegistersDate Valid From: 28 Jun 13Date Valid To: 28 Jun 16Directorate / Department responsible(author/owner):J Robin GatenbyContact details: 01872 252266Brief summary of contentsSuggested Keywords:Target AudienceExecutive Director responsible forPolicy:The document aims to outline theprincipals and procedures for thecompletion of risk assessments for areasand activities within the control of theRoyal Cornwall Hospitals NHS Trust.Health and safety, risk assessment, riskmanagementRCHT PCT CFTMedical DirectorDate revised: 28 Jun 13This document replaces (exact title ofprevious version):Approval route (names ofcommittees)/consultation:Policy & Guidance for Risk AssessmentHealth & Safety CommitteeGovernance CommitteeDivisional Manager confirmingapproval processesHead of Quality and SafetyName and Post Title of additionalsignatoriesSignature of Executive Director givingapprovalPublication Location (refer to Policyon Policies – Approvals andRatification):Document Library Folder/Sub FolderLinks to key external standardsNot Required{Original Copy Signed}Internet & IntranetClinical/QualityAndSafety Intranet OnlyNHSLA Risk Management StandardsIncluding but not restricted to:Related Documents:Health & Safety PolicyRisk Management PolicyPolicy and Guidance for Risk Assessment and Risk RegistersPage 17 of 21

Training Need Identified?Management of Contractors PolicyIncident Reporting PolicyControl of Substances Hazardous toHealth PolicyDisplay Screen Equipment PolicyLone working PolicyWork at HeightControl of noise at workYes – incorporate update into inductionand existing health and safety trainingVersion Control TableDateVersion NoJul 06 V1 Original documentApr 11V2Summary of ChangesRe-draft of whole document.Consultation with members of Health & SafetyCommitteeMay 12 V2.1 Review for NHSLA level 2 ComplianceMay 12 V2.2 Typo correctionsChanges Made by(Name and Job Title)J Robin GatenbyHealth and SafetyAdvisor (Interim)J Robin GatenbyHealth & SafetyManagerJ Robin GatenbyHealth & SafetyManagerAll or part of this document can be released under the Freedom of InformationAct 2000This document is to be retained for 10 years from the date of expiry.This document is only valid on the day of printingControlled DocumentThis document has been created following the Royal Cornwall Hospitals NHS TrustPolicy on Document Production. It should not be altered in any way without theexpress permission of the author or their Line Manager.Policy and Guidance for Risk Assessment and Risk RegistersPage 18 of 21

Appendix 3. Initial Equality Impact Assessment ScreeningFormName of service, strategy, policy or project (hereafter referred to as policy) to be assessed:Policy & Guidance for Risk AssessmentDirectorate and service area: Is this a new or existing Policy?Health and Safety Team ExistingName of individual completing Telephone:assessment:J Robin Gatenby(01872) 25 ext. 22661. Procedure Aim* The Trust is obliged to undertake risk assessment as arequirement of various statutory health and safety duties.2. Procedure Objectives* The document is intended to provide guidance regardingthe Trust procedure and arrangements for themanagement of risks through a process of riskassessment3. Procedure – intended To meet statutory obligations and to identify and manageOutcomes*specific risks associated with activities and groups ofpersonnel.4. How will you measure the Through the health and safety audit process, incidentoutcome?management reviews, return to work reviews, etc.5. Who is intended to benefit All staff of RCHT.from the Procedure?6a. Is consultation required Yeswith the workforce, equalitygroups etc. around thisprocedure?b. If yes, have these groupsbeen consulted?c. Please list any groups whohave been consulted about thisprocedure.*Please see GlossaryYesHealth and Safety Committee7. The ImpactPlease complete the following table using ticks. You should refer to the EA guidance notesfor areas of possible impact and also the Glossary if needed. Where you think that the policy could have a positive impact on any of the equalitygroup(s) like promoting equality and equal opportunities or improving relationswithin equality groups, tick the ‘Positive impact’ box. Where you think that the policy could have a negative impact on any of the equalitygroup(s) i.e. it could disadvantage them, tick the ‘Negative impact’ box. Where you think that the policy has no impact on any of the equality group(s) listedbelow i.e. it has no effect currently on equality groups, tick the ‘No impact’ box.Policy and Guidance for Risk Assessment and Risk RegistersPage 19 of 21

EqualityGroupAgeDisabilityReligionbelieforPositiveImpactNegativeImpactNoImpactReasons for decisionThis policy will be applicable to all staffand the risk assessment process willenhance the safe working environmentfor staff within all age groups.This policy will be applicable to all staffand the risk assessment process willenhance the safe working environmentfor staff including those with a“disability”, whether permanent ortemporary. The risk assessmentprocess will assist in identifying“reasonable adjustments” as requiredby statutory duty.This policy should not impact upon anypersons faith or beliefGenderTransgenderThis policy will be applicable to all staffand the risk assessment process willenhance the safe working environmentfor staff within all gender groups,specifically where legislation imposesdirect action for a specific gender.This policy should not impactPregnancy/MaternityRaceThis policy will be applicable to all staffand the risk assessment process willenhance the safe working environmentfor staff within all gender groups,specifically where legislation imposesdirect action for a specific gender.This policy should not impact upon anypersons raceSexualOrientationThis policy should not impact upon anyperson’s sexual orientation.Marriage /CivilPartnershipThe application of this policy should notimpact upon any maritial or civilpartnership arrangementsYou will need to continue to a full Equality Impact Assessment if the following havebeen highlighted: A negative impact and No consultation (this excludes any policies which have been identified as notrequiring consultation).8. If there is no evidence thatthe policy promotes equality,equal opportunities or improvedrelations - could it be adaptedso that it does? How?Full statement of commitment to policy ofequal opportunities is included in the policyPolicy and Guidance for Risk Assessment and Risk RegistersPage 20 of 21

Please sign and date this form.Keep one copy and send a copy to Matron, Equality, Diversity and Human Rights,c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, ChyveanHouse, Penventinnie Lane, Truro, Cornwall, TR1 3LJA summary of the results will be published on the Trust’s web site.Signed ________________________________________Date _________________________________________Policy and Guidance for Risk Assessment and Risk RegistersPage 21 of 21