Public Board of Directors papers 27.01.22

Physical or psychological

►Health associated infection which did not result in permanent harm ►Affects 1 -2 people ►1 -3 days off work ►Grade 2 pressure ulcer

►No staff attending essential / key training ►RIDDOR / Agency reportable incident ►4 -14 days off work ►Adverse event which impacts on a small number of patients ►Affects 3 -15 people ►Grade 3 pressure ulcer ►Challenging recommendations which can be addressed with appropriate action plans ►Single breach of statutory duty ►Non -compliance with core standards <50% of objectives within standards met ►Unsatisfactory management of patient care – local resolution (with potential to go to independent review) ►Increased length of hospital stay by 4 – 15 days ►5 - 10% variance in schedule from baseline plan ►5 - 10% variance against project budget ►5 - 10% variance on value and/or time to realise declared benefits against profile ►Concern for safety triggering CAF ►Need for further support for child/ young person &/or vulnerable adult. ►Neglect of health needs with minimal impact to health and welfare i.e. missed appointments, non- compliance with treatment. ►Concern re financial abuse of vulnerable adult with mental capacity where the “victim” is unwilling to notify Police/LA. ►One -off verbal abuse with multiple victims and against staff.

►>14 days off work ►Affects 16 – 50 people ►Grade 4 pressure ulcer

►Multiple permanent injuries or irreversible health effects ►An event affecting >50 people

►Small number of recommendations which focus on minor quality improvement issues ►No or minimal impact or breach of guidance / statutory duty ►Minor non - compliance with standards

►Minor recommendations which can be implemented by low level of management action ►Breach of statutory legislation ►No audit trail to demonstrate that objectives are being met (NICE; HSE; NSF etc.) ►Unsatisfactory patient experience directly due to clinical care – readily resolvable ►Increase in length of hospital stay by 1- 3 days ►<5% variance in schedule from baseline plan ►<5% variance against project budget ►<5% variance on value and/or time to ►No safeguarding action is taking place and/or safeguarding issues have been fully addressed. ►One incident of undignified care, delays in service due to a one-off shortage of staffing ►Concern for welfare resolved with discussion with parent/carer or universal services realise declared benefits against profile

►Enforcement action ►Multiple breaches of statutory duty ►Improv ement Notice ►Critical Report ►Low performance rating ►Major non compliance with core standards ►Unsatisfactory management of patient care with long term effects ►increased length of hospital stay >15 days ►Misdiagnosis ►10 - 25% variance in schedule from baseline plan ►10 - 25% variance against project budget ►10 - 25% variance on value and/or time to realise declared benefits against profile ►Moderate physical injury inflicted. ►Neglect of health needs with significant impact to health & welfare i.e. missed appointments, non- compliance with treatment. ►Safeguarding Protection Plan is/remains in place. ►Significant self - neglect requiring hospitalisation ►Concern of financial abuse and/or neglect (including misuse of medication) of

►Multiple breaches of

statutory duty ►Prosecution ►Severely critical report ►Zero performance rating ►Complete systems change required ►No objectives / standards being met ►Incident leading to death ►Totally unsatisfactory level or quality of treatment / service ►> 25% variance in schedule from baseline plan ►> 25% variance against project budget ►> 25% variance on value and/or time to realise declared benefits against profile ►Major/significan t injury inflicted or sustained. ►Protection Plan is being implemented. ►Legal action is being taken. ►The abusive behaviour is persistent and / or deliberate ►The incidents are increasing in frequency and/or severity. ►Serious allegation made against an employee of the Trust towards a child/young person vulnerable adult.

Inspection/ Statutory Duty

►Reduced level of patient experience which is not due to delivery of clinical care

Patient experience

►Insignificant schedule from baseline plan ►Insignificant cost increase ►Insignificant impact on value and/or time to realise declared benefits against profile ►Safeguarding Children/Young People & Vulnerable Adults

Projects

Safeguarding

vulnerable adult without mental capacity.

Risk management strategy and Policy 2021-2024 Document ref: RM01 Version 04

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