COVID‐19 Risk Register
As at 29.09.2020.
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Implementation of flu vaccination across NHS Borders cannot be fully
planned for as no definitive steer has been issued by the Scottish
Seek definitive steer from Scottish Government on age
Government on the age range to be prioritised. Verbal information from the
Action
range
Scottish Government suggests this will be 55+, whereas England has been
advised 50+. There is therefore confusion on who needs the vaccination and
the impact this will have on capacity, resource and funding.
NHS Borders does not have sufficient storage for vaccinations for
vaccinations and this issue has been raised over a number of years without
Action
Flu immunisation plan in place by October 2020
any action being implemented to mitigate this risk. This has now become a
critical issue in NHS Borders being able to deliver the winter flu programme.
Local refrigeration capacity for vaccines and vaccine delivery schedules are
crucial components in the seamless steady administration of vaccines to
patients.
Likely (4 Strong
V High
Action
Purchase of fridge to store vaccines
Managed
Business as
1834 Organisational wide
possibility that
Extreme (5)
Very High
High (15)
Public confidence in NHS Borders may be impacted leading to adverse
(20)
(Treat)
usual
publicity and reputational damage.
this could occur)
Decision making and leadership direction to be strengthened in regards to
seasonal flu programme requirements.
Staffing required to support the programme is not available, capacity to
Investigate the use of mitiary colleagues to assist in
undertake increased activity not sustainable for flu programme. Any large‐
Action
delivering vaccinations programme
scale vaccination programme will need to be delivered by a workforce which
is facing additional demand due to the longer‐term impacts of the COVID‐19
pandemic and lockdown, and which may have reduced capacity, due to the
need to protect vulnerable staff from frontline work and for potentially
infected staff to self‐isolate.
Investigate where funding is coming from and how much
Action
Vaccination journey extended due to new processes in place in line with
is available
COVID19 restrictions. In the context of social distancing, use of personal
protective equipment and increased time necessary for immunisers to
Control
Use of Near Me
Control
Training for Near Me
Impact of COVID‐19 on existing MH patient population and the impact on
Control
Use of PPE to allow face to face visits
the general population's mental health is likely to rapidly increase. This will
Control
Clinical space at Cauldshiels
put pressure on primary care and secondary care MH services.
Expand use of Near Me to allow group work and
Action
improvement in IT connection
Learning Disability population are experiencing long term increased isolation
Action
Increase clinical space for face to face appointments
causing pressure on informal and formal carers as well as their own mental
wellbeing. Resilience of care arrangements are highly likely to be
MH primary care options appraisal and implement
Action
compromised increasing the risk of breakdown.
preferred option
Likely (4 Strong
Mental Health &
V High
Medium
Control
Wellbeing plus service in place
Managed
1813
possibility that
Extreme (5)
Very High
Safety
Learning Disabilities Insufficient clinical space to undertake face to face consultations due to the
(20)
(9)
(Treat)
this could occur)
Utilising local area coordinators and mobilisation of day
impact of COVID‐19 on the operation of health centers and social distancing.
Control
service staff to support people in the community
Unable to deliver face to face groups/virtual groups due to COVID‐19
Additional care packages for vulnerable adults with
Control
restrictions and lack of Near Me functionality.
learning disabilities
Control
Temporary respite arrangements in place
LD and MH day centres are closed due to COVID‐19 restrictions resulting in
Further develop the mobilisation plan to accomodate the
increased pressure on formal and informal carers with the likely result of
Action
anticipated increase in service demand
increase carer breakdown and physchological/ mental distress.
1
COVID‐19 Risk Register
As at 29.09.2020.
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Likelihood
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C
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ris
Weekly recovery meetings in mental health and learning
Control
disability services
Testing and clinical support arrangements have been delivered to older
Weekly COVID‐19 provider support group to ensure all
adults and learning disability registered care homes. However, similar risks Almost Certain (
Control
national and local guidance and support is in place to
Mental Health &
remain in supported living arrangements for adults with learning disabilities 5 This is expected
V High
No escalation
reduce the risk of infection
Managed
1815
Major (4)
High (12)
Safety
Learning Disabilities as evidenced by increased mortality during pandemic so these risks may be
to occur
(20)
expected
(Treat)
reduced if testing and clinical support was expanded to supported living
frequently)
Escalated to Gold Command and public health with a
Action
services.
request to role testing to supported living environments
Control
Early detection systems in place
Control
Staff training/ hygiene
COVID19 outbreak management. Large outbreaks/ clusters may occur in
Control
Outbreak management protocols
various settings including NHS premises, care homes or other community
Likely (4 Strong
Control
Environmental and social distancing measures
No escalation Medium
Managed
1730 Organisational wide settings. This would have detrimental impact on staff, patients, service and
possibility that
Major (4)
High (16)
Control
Staff working from home where appropriate
Safety
expected
(6)
(Treat)
reputation of NHS Borders. Availability of appropriately trained public health this could occur)
Control
Monitoring staffing levels
staff. Access to infection control advice and control limited.
Memorandum of understanding with local health boards
Control
and regular discussions with infection control team
Health protection and testing temporary contract
Public Health protection resilience compromised due to uncertain capacity
Action
recruitment to be undertaken
to face future challenges and outbreaks. Expectation of multiple outbreaks Likely (4 Strong
No escalation Medium
Managed
1861
Support Services
in Autumn will impact on resource of certain public health teams such as
possibility that
Major (4)
High (16)
Health Protection Nurses business case with focus on
Workforce
expected
(8)
Action
(Treat)
Health Protection, Test and Protect and Testing all requiring ability to flex this could occur)
tracing to be approved and recruitment undertaken
capacity should outbreaks occur.
Control
Mutual aid between health boards in place
SACT staff are at high risk of being a carrier of COVID‐19 additional steps are
Control
Implement social distancing measures wherever possible
required to protect fellow staff but especially patients in this high risk
Likely (4 Strong
No escalation Medium
Managed
1702
Acute
category. Patients receiving SACT and their family members have already
possibility that
Major (4)
High (16)
Control
Ensure appropriate PPE available
PPE
expected
(8)
(Treat)
been advised to isolate.
this could occur)
Control
Staff training in PPE usage
Risk of fatal neutropenic sepsis greater in someone who has COVID‐19.
Control
Reduce footfall to Borders Macmillan Centre
Weekly return submitted to Scottish Government;
Some areas of normal financial control have been temporarily suspended in
Action
highlighting issues requiring agreement from Scottish
order to allow key staff to focus on areas of clinical priority. Interim
Government
arrangements have been put in place for revised governance however there Likely (4 Strong
Control
Authorisation limits in place
No escalation Medium
Managed
Financial
1716 Organisational wide is a risk that these may not be fully complied with in current circumstances, possibility that
Major (4)
High (16)
Action
Enforce authorisation limits
expected
(9)
(Treat)
governance
leading to unwarranted variation. In addition, national uncertainty over
this could occur)
Reviewing spend and commitments to confirm
financing of Covid‐19 related expenditure means that there is a risk that the
requirement. Agree scope and timescales for
Action
board’s annual plan may no longer be deliverable within available resources.
implementation of any changes to interim financial
governance arrangements.
Laundry department averages £300,000 per annum income from external
Reduce staff levels through reduction in excess hours and
contractors such as the hotel industry through laundering items. As these
Action
overtime, reducing temporary staffing and suspend
premises are currently closed income is not being accrued. Target incomes
replacement of staff leavers
are not being met which will impact on budgets and savings. There is a risk
Likely (4 Strong
No escalation Medium
Managed
Business as
1727
Support Services
that this custom will not return to expected levels due to possibilities of
possibility that
Major (4)
High (16)
Control
Reduction in supply costs
expected
(9)
(Treat)
usual
businesses not reopening or losing custom during this period of uncertainty. this could occur)
Finance continue to monitor the ledger regularly, if there
Catering department has reduced footfall in canteen, reduction in use of
Control
are any changes in assumptions these are reflected within
vending machines and no orders for meeting refreshments which impacts
the modelling
on income targets.
2
COVID‐19 Risk Register
As at 29.09.2020.
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Likelihood
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C
Co
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ris
Supply of PPE given to all wards with eye protection
Control
shields
Patients within the mental health wards have often got no capacity to
staff have been given training in requirements of correct
Control
understand the current risks with the COVID 19 Pandemic. Patients may
usage of PPE
require restraint by nurses to protect harm to themselves or others. This
arrange infection control walk rounds to ensure
does not comply with social distances goverment requirements. Staff could Likely (4 Strong
Action
compliance of PPE and correct usage of infection control
Mental Health &
No escalation Medium
Managed
1748
be at risk of infection if they have to restrain patients, there could be delay
possibility that
Major (4)
High (16)
measures
Safety
Learning Disabilities
expected
(9)
(Treat)
in restraint to allow staff to put PPE on and increased risk of harm to patient this could occur)
ensure all wards have SOP in place for restraint procedure
Action
or other if staff are unable to intervene quickly with PPE on.
during covid 19
Increased risk of abscondsions, self harm, injury to staff and patients during
Control
Daily risk assessment of patients using safety care plan
restraint.
Control
All staff trained in de esacaltion and PMAV
Control
Personall alarms on ward for staff
Covid requires a different model of staffing which will result in an increased
financial expenditure, while it is anticipated that funding may be available
from Scottish Government this is currently unclear whether this will meet
the level of expenditure.
Likely (4 Strong
No escalation Medium
All increased expenditure agreed by Q & monitored
Managed
Financial
1763
Acute
possibility that
Major (4)
High (16)
Control
Increase costs ongoing in relation to PPE and different models of care will
expected
(9)
regularly and fed into Gold Command.
(Treat)
governance
this could occur)
require increase funding.
Unable to meet agreed budget. Resulting in the organisation meeting its
statutory financial targets.
Likely (4 Strong
Control
Regular monitoring of patients
Mental Health &
Huntlyburn ring fenced bed for in patient detox put on hold until further
Medium
Managed
Business as
1823
possibility that
Major (4)
High (16)
Very High
Recommencement of in‐patient detoxification in
Learning Disabilities
notice.
(8)
Action
(Treat)
usual
this could occur)
Huntlyburn
Control
Encouraging staff to work from home
Almost Certain (
Disruption to clinical input across the CAMH service and potential immpact
Control
Using clinic space within Cauldshiels
Mental Health &
5 This is expected
No escalation Medium
Managed
1765
on targets due to poor internet connection and speed and lack of any wifi in
Moderate (3)
High (15)
IT
Learning Disabilities
to occur
expected
(9)
Action
Look for additional clinical space as it becomes available
(Treat)
the Andrew Lang Unit.
frequently)
Action
Liaise with IT as required
Expected increase in COVID‐19 positive cases has encouraged the Scottish
Action
Calling in people from tracing bank
Government to ask health boards to prepare for this scenario. This requires
Recalling people from substantive post who have
Action
the Trace and Protect team to be fully staffed to manage the expected
previous experience in tracing team
demand which if it does arrive will happen suddenly without time to
Almost Certain (
Recruit 6 x band 6 health protection nurses and additional
Action
reactively get staff in place. To prepare the Trace and Protect team will be 5 This is expected
No escalation Medium
staff
Managed
1890
Support Services
Moderate (3)
High (15)
Workforce
required to pull in staffing resource from clinical boards and support services
to occur
expected
(9)
Liaising daily with national contact tracing centre around
(Treat)
Control
where staff has had experience of working within this team previously. This
frequently)
capacity and need for mutual aid
has the potential to impact on clinical boards recovery planning and return
Escalate to national level for patients being referred cross
Action
to business as usual.
border via national groups and HPS
If clinical boards are unable to release staff, this would risk the mandatory
Control
staff training in PPE and how to put this on
Use of PPE in mental health wards during the COVID 19 pandemic.
weekly walkround spot checks using infection control
Goverment guidance recommends that all patients should be considered as
Action
process to ensure staff are adhearing to guidance
a positve case within the inpatient wards and staff should be 2 metres away
3
COVID‐19 Risk Register
As at 29.09.2020.
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Likelihood
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C
Co
Actions
ris
from patients. If staff are not able to comply with 2 metres distance PPE
regular updates from Health improvemnent scotland on
Control
should be worn at times and sessional use would apply when providing
Possible (3 May
ppe guidance
Mental Health &
No escalation Medium
Managed
1747
general care.
occur
Extreme (5)
High (15)
Control
Infection control group specifically for PPE
Safety
Learning Disabilities
expected
(6)
(Treat)
The risks of not using the PPE correctly increase when patients are unable to occassionally)
contact other boards to see what challenges mental
Action
comply or understand the 2 metre guidance which means staff will have to
health units have using ppe.
wear this all the time.
Control
Staff safety briefing
No clear sessional use in mental health wards leads to staff confusion
Control
safety huddle daily to escalate concerns or issues in wards
regarding the use of PPE.
Control
regular staff breaks
National there is a T34 SLWG that have a clinical lead and
Control
procurement lead per board which are monitoring the
supply of the infusion lines
McKinley T34 pumps:
1. A significant number of pumps missing within NHS Borders
Possible (3 May
Locally there is creation of task and finish group this is
2. National shortage of infusion lines due to Covid
No escalation
Managed
1821
Acute
occur
Major (4)
High (12)
Low (2)
through Alis Nichol (PMO). Looking to centralise a pump
Medication
3. New version 3 of the pumps have software issues and version 2 are no
expected
Control
(Treat)
occassionally)
register to identify the activity and know where stock is.
longer being manufactured (therefore if we have issues if we need to
This is across Acute & Community.
replace or increase stock).
There is a National Order of the v.3 model, but would
Action
require a software update once we get these.
Aerosol generation procedures within the ward require precautions to be in
Trying to find a suitable device to mitigate some of the
Action
place to protect staff from the particles which have the potential to cause
risks including the redi room.
Likely (4 Strong
infection. Within ward 15 there are no bed areas with either negative
No escalation Medium
Liaise with Estates and Infection Control around actions to
Managed
1811
Acute
possibility that
Moderate (3)
High (12)
Action
PPE
pressure or double sets of doors to minimise aerosol generating particles
expected
(6)
mimimise risk
(Treat)
this could occur)
spreading directly into the ward corridor.
Liaise with other teams in the hospital dealing with
Action
This is an ongoing risk for the paediatric ward as the winter viral season
similar situations
Testing service for staff and patients. Laboratory capacity not available in
Possible (3 May
Action
Increase laboratory capacity in NHS Borders
No escalation Medium
Managed
1729 Organisational wide NHS Borders to undertake appropriate tests. Staffing for testing service may
occur
Major (4)
High (12)
Action
Increasing testing staff numbers and training
Safety
expected
(6)
(Treat)
not have capacity to undertake appropriate tests.
occassionally)
Control
Deploy staff from other areas to support
Additional staff being identified from across the
Action
organisation to support with contact tracing.
Action
Working with national advisory group on methodology.
Request to PHS to provide weekly forecasts of how
Action
demand may change so HPTs can be responsive to this.
Request the provision of escalation capacity from PHS to
Action
support boards where demand significantly exceeds
capacity.
Monitor staff time/call duration over the initial period of
Control
the service to check assumptions made in the initial
service proposal.
Rotate non‐shielding staff through allocated on‐site office
Action
Contact Tracing Service (Test and Protect)
to support with training and supervision.
There was a requirement from Scottish Government for NHS Borders to re‐
4
COVID‐19 Risk Register
As at 29.09.2020.
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There was a requirement from Scottish Government for NHS Borders to re
Escalation to chief executives and DPH group and PHS if
establish contact tracing. This is now operational and capacity within this
Control
appropriate.
service is gradually being increased. Staff are being redeployed from across
the organisation to support this service.
Escalate issues via national contact tracing group and
Control
Likely (4 Strong
chief executives and DPH group if required
No escalation Medium
Managed
1731 Organisational wide Whilst the service is operational, there are a number of risks to highlight and possibility that
Moderate (3)
High (12)
Safety
expected
(4)
Supervision in place from HPT trained staff and
(Treat)
manage in the running of the service. These are outlined in the section
this could occur)
Control
Consultant. Regular staff huddles to support learning and
below.
support
Promote and facilitate home working for all control
Failure of contact tracing may lead to a resurgence of COVID19 infection. It
Control
tracing staff.
is a government requirement that we have a local contact tracing service.
When contact tracers are on site they will not share an
Control
office or equipment (laptops/headsets), to reduce
transmission in the workforce.
Home working guidance issued to staff and home working
Control
risk assessments to be completed.
Constantly review service provision as new guidance
Action
issued. Ensure staff aware that it is a developing and
changing service from the outset.
Secondment arrangements to be put in place for each
Action
member of staff.
Requests for staff to return to substantive role must be co‐
Control
located through PMO/HR deployment process.
Control
Monitor service spend and activity.
Impact on business as usual services such as:
Action
Review of current vaccination uptake rates
Reduced uptake of childhood vaccination rates
Action
Review of ADP commisioned services
Possible (3 May
Pausing of national screening programs
No escalation Medium
National screening programs under continuous review at
Managed
Business as
1726
Support Services
occur
Major (4)
High (12)
Action
Disruption to health and well being services
expected
(8)
national level
(Treat)
usual
occassionally)
Pausing of diabetes prevention strategy
Action
Review of impact that COVID19 has on health inequalities
Disruption to ADP commissioned services
Control
Demand and capacity plan
Control
Accommodation available to "surge" into
Primary &
Risk of a surge of assessment demand should "lockdown" relaxation
Likely (4 Strong
No escalation Medium
Control
Add additional shift
Managed
Business as
1753
Community
precipitate a surge in Covid‐19 infection rates, plus a return to previous
possibility that
Moderate (3)
High (12)
expected
(6)
Control
Can pull back ANP from BGH
(Treat)
usual
Services
levels of non covid activity during the out of hours period
this could occur)
Control
Access GP and nursing volunteer pools
Control
Use of "Near Me" technology
5
COVID‐19 Risk Register
As at 29.09.2020.
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The increased number of patients needing critical care has increased the
demand for drugs used in both anaesthesia and critical care and this
demand will need to be managed carefully.
The UK medicine supply chain has operated on a ‘just in time’ basis for many
years and recently there have been several challenges with medicines
shortages. The UK Government has reserved responsibility for supply and
NHS England are leading on this on behalf of the UK.
Possible (3 May
NHS Borders has been acting in line with advice from National Procurement
No escalation Medium
Continue to follow advice from National Procurement and
Managed
1719 Organisational wide
occur
Major (4)
High (12)
Action
Medication
and Scottish Government during this time. The advice was to not stockpile
expected
(8)
Scottish Government during this time
(Treat)
occassionally)
as there was work on going to manage stocks across the UK and any
excessive ordering could affect the supply.
NHS Borders medicines supply model has operated with a ‘just in time
approach’. With the additional critical care beds coming on stream, there
have been moves to increase the stock for some critical medicines in an
incremental basis so as not to destabilise the supply chain. Attempts to
order a significant additional quantity of these medicines has been
challenged by National Procurement and at UK level.
Covid‐19 and government advice ‐ Due to Covid‐19 and government advice
Contacting pharmacies to ask to supervise for the most at
Action
re self isolating we are have to work in a completely alien way running with
risk.
far more risk and making decisions that are out with the orange guide lines Possible (3 May
Offer a locked medicine box to the most vulnerable if
Mental Health &
Medium
Managed
1706
and usual pharmacy dispensing. We have to drastically reduce our usual
occur
Major (4)
High (12)
High
Control
they are having to have a few days ORT kept at there
Medication
Learning Disabilities
(9)
(Treat)
dispensing guidelines providing up to 14 days of 'holiday prescriptions' for
occassionally)
home.
people self isolating due to Covid‐19.
Control
Staff will deliver if required to patients self isolating
Pharmacies are no longer able to offer daily supervised and we have to
4 hour induction training period for staff mobilisation in response to COVID‐
Compulsory Moving & Handling Awareness Sessions for
Control
19 does not meet NHS Borders policy or statutory/legal requirements
Covid‐19 HCSW Cohort
regarding information, instruction, training and supervision e.g. moving and
Staff whom undertake a full contract following the COVID‐
handling, PMAV, basic life support, health and safety.
Control
19 period will be required to undertake the full
Likely (4 Strong
No escalation
Statutory/Mandatory Training
1710 Organisational wide
Statutory/mandatory training suspended during pandemic meaning staff
possibility that
Moderate (3)
High (12)
High (12)
Tolerate
Training
expected
requiring full training will not necessarily receive training. Potential for
this could occur)
COVID 19 recovery plan NHS Borders
claims to be made against the organisation.
statutory/mandatory training consideration to bringing
Action
training back in place with appropriate social distancing
Staffing levels for teams which offer statutory training are single points of
needs considered.
failure.
Control
Pre admission testing
Control
Over 70s testing
Redesign of ward layout to adhere to social distancing
Control
where possible
Primary &
Possible (3 May
Community Hospitals ‐ Minimal reduction in beds within community
No escalation Medium
Control
Cohorting of patients
Managed
Business as
1839
Community
occur
Major (4)
High (12)
6
COVID‐19 Risk Register
As at 29.09.2020.
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Likelihood
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C
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ris
1839
Community
occur
Major (4)
High (12)
hospitals affects ability to adequately social distance
expected
(8)
Control
Minimising patient visiting
(Treat)
usual
Services
occassionally)
Control
Use of appropriate PPE
Action
Review of shared space within community hospitals
Control
Signage in place
Ensure that cubicles 7 & 8 are sectioned off from the rest
Control
of the unit by double doors on either side
Door from front of MKU/BSU signposted as no entry so it
Control
is not used for access
Covid Ward ‐ CV4 (Ward 12) temporarily closed due to low numbers of
Droplet precautions signage to use used for cubicle doors
patients (based on modelling) and organisation taking opportunity to decant
Control
when in use
Ward 4 into Ward 12 for refurbishment of Ward 4.
Possible (3 May
No escalation Medium
Control
PPE available outside rooms for staff to use
Managed
1871
Acute
occur
Major (4)
High (12)
Safety
expected
(6)
Domestic services aware of room use and need for
(Treat)
Covid‐19 positive patients ‐ cohort 1 and / or cohort 2 ‐ probable Covid‐19
occassionally)
Action
enhanced cleaning and should clean other areas first
with negative PCR, high risk score above 4 on medical criteria will be
before Covid cubicles
admitted to cubicles 7 & 8 in MKU, under general medicine.
Staff who have previously been shielding will not work
Control
within these cubicles and wok in BSU / are not rostered
onto night duty when there is less cover
Action
Covid resus trolley is in place
Single point of triage and that routes the patient to the
Control
correct pathway
Increased footprint within ED to 23 cubicles & increased
Control
staffing within ED to support early assessment
Social media and communication advising people not to
Action
attend ED unless it is an emergency
Control
Referral to the Covid hub for appropriate patients.
All patients admitted are having a Covid swab prior to
Action
transferral to admission ward. This is to assist in early
cohorting and treatment plan
Covid cohorting tool ‐ patients who have a negative swab
Likely (4 Strong
Action
No escalation Medium
but have diagnostic features of covid
Managed
1841
Acute
Unscheduled Care attendances and admissions returning to pre‐covid levels. possibility that
Moderate (3)
High (12)
Safety
expected
(6)
(Treat)
this could occur)
Refresh of the Daily Dynamic Discharge to plan and
identify patients that could be discharged in the morning
Action
rather than the afternoon to stop maintain flow through
the system
Working with Integrated Hub to ensure patients are
Action
identified early who require intermediate care or
enablement (including transfers to community hospitals)
7
COVID‐19 Risk Register
As at 29.09.2020.
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At ward level put in place key points of day know where
Action
next bed/bay is and if they can't then they escalae to their
line manager
In ED we have refreshed the escalation process to ensure
Action
timely review with expections by 3 hours a plan that
patient will be admitted or discharged.
Control
PPE review process developed
Board to review and agree cleaning of single use PPE.
Control
Cleaning to stop as soon as additional stock levels arrive
Process for cleaning face shields agreed and guidance
Control
issued
Control
Regular COVID‐19 briefing sessions
PPE safety officers introduced to check ward stock and
Control
correct wearing of PPE
Control
Latest Department of Health guidance issued to all staff
Control
PPE donning and doffing training
Face Fit Testing – Qualitative and now Quantitative
Control
testing available
Occupational Health notified of FFP3 stocks to allow
Control
changing face fit tests onto new products
Control
Jupiter system available for staff unable to be fit tested
The availability of Personal Protective Equipment across NHS Borders has
ITU/Theatres and ASDU trained to clean Jupiters and
been impacted due to global nature of Covid‐19. In addition the usage of
users trained to inspect Jupiter head tops for damage
Likely (4 Strong
Control
PPE has changed daily/weekly due to Department of Health guidance, along
No escalation Medium
prior to use. Single use headtops monitored for damage
Managed
1700 Organisational wide
possibility that
Moderate (3)
High (12)
PPE
with the need for wider usage to protect staff during the outbreak.
expected
(8)
due to cleaning
(Treat)
this could occur)
NHS Borders moved to sustained transmission across Health and Social Care
resulting in an increase in PPE use.
Control
Process for requesting PPE stocks has been formalised
Models of PPE usage being developed and linked to
Control
monitoring system of PPE stock
Tristel Fuse used for cleaning/disinfection does not cause
Control
the same level of damage as other cleaners
Occupational Health management system for
Control
self/management referral
Control
Single point of contact at health board contact for PPE
Control
Additional PPE on order e.g. Jupiter head tops
PPE committee meets 3 times per week with
Control
representation from the 3 clinical boards and social care
8
COVID‐19 Risk Register
As at 29.09.2020.
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PPE usage modelled against bed occupancy with
Control
dashboard developed showing use and stock available
PPE stock supplied 24/7. Supply available on request with
Action
control measures.
Bed modelling being undertaken by Philip Lunts for
Action
anticipated demand
Bid in for funding for additional staffing into recovery
Action
group for Huntlyburn
Control
Some staffing capacity been provided
Employed half time social worker via reinvestment from
Control
Cauldshiels closure to expedite discharges on Melburn
There is assumption with limited literature nationally that there will be an
and Lindean
increase in demand on community and in patient mental health services
Control
Temporary respite contract for LDS
post Covid‐19. There is a risk that demand will outstrip capacity within the Likely (4 Strong
Mental Health &
No escalation Medium
Additional funding request to recovery plan for additional
Managed
1819
community and in patient setting. Unexpected presentations have been of a possibility that
Moderate (3)
High (12)
Action
Workforce
Learning Disabilities
expected
(6)
staffing for CAMHs
(Treat)
higher acuity and have been first presentation psychosis and relapse
this could occur)
alongside predicted conditions of anxiety, depression, increase in suicidality
Control
Temporarily suspended detox admissions to Hunlyburn
and PTSD and EUBPD.
Recruiting additional permanent half time psychologist to
Action
CAMHs
SG review for CAMHs for 21.08.2020 to support
Action
improving processes and make efficiencies
Agreed to deliver a primary care MH service funded by
Action
PCIP and Action 15 to begin service delivery from
September 2020
Since the start of COVID we have had our Consultant Psychiatrist increase
his time here from 4 sessions to full time.
The impact this has had on the team at such an unbelievably difficult time
has been pivotal for us to be able to, as a team ,work together and deliver
the best and safest service/treatment in a time when the very way we had
known how to work was taken from underneath us. At present this still feels
very fragile and the changes we have made and starting to move back to a
more 'normal' way of working could change almost at any time, and all this
whilst still meeting all the HEAT standards. It has also allowed us to see what Likely (4 Strong
Mental Health &
Medium
1770
we need to do as a team moving forward and how much the need for a
possibility that
Moderate (3)
High (12)
Tolerate
Safety
Learning Disabilities
Consultant Psychiatrist is if we are to offer a mental health service to our
(4)
this could occur)
most vulnerable in society and with that keeping the doors of A&E and Adult
Mental Health freer . We also must take into account the recent DRD during
COVID which has undoubtedly spiked. We also have approx.65 more people
on Prescriptions in the last 12 months a jump of almost 23% which we can
only see increasing. With a Consultant in BAS fulltime we have also been
able to be one of the leading health boards in introducing a treatment
options such as Buvidal and this was during COVID, our ability to offer and
supply such a service would be greatly hindered (if we could do this at all)
without having the increased hours of Cons Psych We also have funding for Almost Certain (
Control
Social distancing risk assessment completed
Photocopier in managers room and closer than 2 meters from desk, only
Mental Health &
5 This is expected
No escalation
Action
Move photocopier to spare office
Business as
1782
photocopier in base and all use this also very noisy and difficult to hear
Minor (2)
High (10)
Low (1)
Terminate
9
COVID‐19 Risk Register
As at 29.09.2020.
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C
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Actions
ris
1782
photocopier in base and all use this. also very noisy and difficult to hear
Minor (2)
High (10)
Low (1)
Terminate
Learning Disabilities
to occur
expected
usual
when using video conferencing and 'Teams'.
Action
Top desk to IM&T to add internet cable to spare office
frequently)
SOP by Shona Milne will have escalation triggers.
With the expansion of ICU capacity across NHS Scotland and the significantly
Action
Complete
increased demand on critical care beds in Scotland and globally, shortages in Unlikely (2 Not
Action
Sourced alternative makes & supplies
the availability and supply of essential ICU consumables has been noted.
No escalation Medium
Managed
1745
Acute
expected to
Extreme (5)
High (10)
National Procurement will advise if other hospitals have
ITU capacity
expected
(8)
Action
(Treat)
happen)
the same products
There is no back orders and is a weekly order. There is no back order
We've given National Procurement estimated usage
allowed and there is a short turnaround for the shortage report.
Control
based on potential demand figures
There is a short window of intervention and can prevent complications for
A space has now been sourced in OH Newstead to
newborns and are part of routine antenatal and post natal care. Therefore
Control
provide a 2 times a week clinic for babies to be brought
universal national neonatal screening programmes are to continue during
to.
the current COVID‐19 contingencies.
PPE is now available for community clinic and transport
The hearing screening programme is affected due to increased 6 hour
Control
has been arranged to get staff to the clinic.
discharge rates, community reluctance to attend hospital for appointments Possible (3 May
Medium No escalation Medium
Managed
Business as
1704
Acute
and the lack of space available in the community to run follow up clinics.
occur
Moderate (3)
(9)
expected
(4)
Liaison with national programme leads to ensure our
(Treat)
usual
occassionally)
Control
Babies will miss screening and hearing loss will not be identified in the time
service remains equitable with others within Scotland.
frame set out in the current programme therefore preventing interventions
Pathway has been agreed with NHS Lothian for our
to occur. We typically find 1 ‐ 2 babies each year with bilateral hearing loss
Control
patients from NHS Borders
that are subsequently found to have neurosensory loss requiring long term
Audit of community clinic uptake by our service users and
intervention, early intervention is beneficial to the long term outcomes.
Action
feedback to the national team
Referral pathways are also affected due to NHS Lothian taking the decision
Single points of failure ‐ there is limited cover for some skills
Control
Third party can offer partial support to infrastructure
Infrastructure ‐ Remote working is increasing the pressure on infrastructure.
Action
Increase bandwidth
Possible (3 May
Send organisational instructions for remote working to all
Medium No escalation
Action
Managed
1712 Organisational wide Trak configuration – the speed of making floor plan changes to Trak has left
occur
Moderate (3)
Low (2)
staff
IT
(9)
expected
(Treat)
us with a possible data legacy issue that may take some time to unpick and
occassionally)
Follow Scottish Government and national security team
Control
recover from which could affect all our reporting as we try to go back to
guidance
more usual definition of beds
Product for extra layer of security being issued by the
Action
Scottish Government
Traceability of equipment currently being issued for COVID‐19 response is
Possible (3 May
Process to be put in place to ensure the location of
not being accurately recorded on equipment registers. There is a potential
Medium
Action
Business as
1728 Organisational wide
occur
Moderate (3)
High
Low (3)
equipment issued during COVID‐19 response is recorded
Tolerate
for equipment to remain after the response unregistered in the
(9)
usual
occassionally)
maintenance log thus not being adequately maintained. This could
Action
Audit of current equipment locations
Action
Audit of all areas to assess ability to socally distance
Considering options to create more socially distanced
Action
space
Action
Handover spaces identified on all three floors
Staff are unable to socially distance themselves due to the layout of the BGH Possible (3 May
Microsoft Teams being implemented for all business
building.
Medium No escalation Medium
Action
Managed
1740
Acute
occur
Moderate (3)
meetings
Safety
(9)
expected
(9)
(Treat)
occassionally)
A SLWG has been set up to discuss how we can
This includes stairwells, offices, corridors.
Action
implement social distancing
10
COVID‐19 Risk Register
As at 29.09.2020.
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Likelihood
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ris
Signage is now in place throughout the hospital to keep
Control
left and highlighting where hand gels are. Signage for
visitors to wear a face mask is also in situ
As part of our COVID response the current crisis service function was moved
Control
regular supervision with staff
into the CMHTs. THe staff from the crisis service were then able to manage
Control
offer of rotation of staff from other teams
and staff the out of hours service covering the hours 13.00 to 09.00
Possible (3 May
Staff completing off duty and staff able to take annual
Mental Health &
Medium
Medium
Control
Managed
1752
everyday and 24 hours at the weekend. This means that the current crisis
occur
Moderate (3)
High
leave
Wellbeing
Learning Disabilities
(9)
(9)
(Treat)
team staff are working only late shifts and night shifts. There is a risk that
occassionally)
team and mental health managers review current
this staff group will not be able sustain this, sickness could increase and
Action
symstem with staff within the next 4 weeks
there could be dentimental effect on their wellbeing following this shift
As a consequence of a higher than normal level of staff sickness,the build up
Control
Demand and capacity Plan
Primary &
Possible (3 May
of outstanding staff annual leave due to current controls and pull back of
Medium No escalation Medium
Control
Buddy system for management team
Managed
1754
Community
occur
Moderate (3)
Workforce
staff from other services, the pool of employess available to over the service
(9)
expected
(6)
Control
Volunteer GP/Nursing pools established
(Treat)
Services
occassionally)
may become diminished.
Control
Existing BECS escalation procedure
Primary &
Possible (3 May
Closure of Covid‐19 Centre and the return of BECS, incorporating Covid‐19
Medium No escalation Medium
Managed
Business as
1755
Community
occur
Moderate (3)
Control
BECS/Covid‐19 Centre currently in Day Hospital
assessment centre, to its' original location.
(9)
expected
(9)
(Treat)
usual
Services
occassionally)
Allocating visiting slots, with staggered times, limiting the
Control
number of visitots on a ward at any one time
Dedicated visitor needs to be identified by patient &
Action
documented in notes
Communication sent out to visitors & staff regarding
Action
expectations & processes
Action
Identify a visitor coordinator for each shift
Covid screening questions with each visitor prior to them
entering the ward. Entry only allowed if visitors
Possible (3 May
Potential risk of spread of Covid‐19 to staff, patients & public due to visiting
Medium No escalation Medium
Action
asymptomatic and not had contacts with anyone
Managed
Business as
1827
Acute
occur
Moderate (3)
taking place within an Planned Care environment.
(9)
expected
(9)
confirmed or suspected of having Covid over previous 14
(Treat)
usual
occassionally)
days
Staff will advise visitors of hand hygiene requirements
Action
and they must wear a face mask whilst in the hospital
Control
Beds in bays at 4 to assist in social distancing
Nursing staff available to help support patients unable to
Action
understand the requirements for social distancing
Control
Signage displayed in corridors to promote 2m distancing
Restricting the days people can visit and number of
Control
visitors per bay. Patients are only allowed 1 designator
visitor
There is a booking system for the designator visitor to
Control
book a visit through
Placement of the visitor to allow 2m socially distance
Action
space
11
COVID‐19 Risk Register
As at 29.09.2020.
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Likelihood
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C
Co
Actions
ris
Control
Visitors to wear facemask whilst in the hospital
Possible (3 May
Reintroduction of visiting to unscheduled care ward areas during Covid‐19
Medium No escalation Medium
Managed
Business as
1828
Acute
occur
Moderate (3)
pandemic.
(9)
expected
(9)
In CV4 as per National guidelines there is no visiting
(Treat)
usual
occassionally)
unless under exceptional circumstances. If there is a
Control
visitor, then patient likely to be moved to a cubicle and
PPE required for visitor
MKU have their own entrance which is locked and staff
Control
can buzz visitors in
MKU will offer an appointment system to ensure control
Action
of amount of people visiting. These can be pre‐booked in
advance
Essential visiting in place (end of life care, vulnerable
Control
patients, etc) where they can be 2 visitors per patient
Restricted & managed volumes of patients in department
waiting rooms & one family member per patient unless
Control
required due to patient being vulnerable, etc, in line with
phased reintroductin of patient centred visiting
All relatives are asked for their contact details in order to
Possible (3 May
Control
assist with Track & Trace (if required) and are screened
Medium No escalation Medium
Managed
Business as
1829
Acute
Patient visiting in the ED Department
occur
Moderate (3)
using the appropriate Government guidance
(9)
expected
(9)
(Treat)
usual
occassionally)
Bed spacing: 1 trolley per cubicle except in Resus 1 & 2
and Room 12 where there are 2 per space. Patients are
Control
risk assessed who can go into Resus 1 & 2 and Room 12 to
minimise the risk of infection spread.
Control
Current general precautions: rigorous cleaning of rooms
All relatives remains in the cubicle at all times until the
Control
patient is either discharged or admitted
SCBU & Ward 15 only allowing parents / guardians
Possible (3 May
Control
Potential risk of spread of Covid‐19 to staff, patients & public due to visiting
Medium No escalation Medium
permitted and should remain with the child at all times
Managed
Business as
1830
Acute
occur
Moderate (3)
taking place within Ward 15 & SCBU.
(9)
expected
(9)
(Treat)
usual
occassionally)
Control
Signage displayed in corridors to promote 2m distancing
Labour Ward: In addition to birth partner, allowed a
Control
second birth partner as long as no Covid symptoms &
maintain physical distancing
Possible (3 May
Potential risk of spread of Covid‐19 to staff, patients & public due to visiting
Medium No escalation Medium
Ward 16 Maternity: In additionl to birth partner, one
Managed
Business as
1831
Acute
occur
Moderate (3)
taking place within Labour Ward & Ward 16 Maternity
(9)
expected
(9)
Control
designated visitor is permitted, as long as no Covid
(Treat)
usual
occassionally)
symptoms and maintain physical distancing
12
COVID‐19 Risk Register
As at 29.09.2020.
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Likelihood
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C
Co
Actions
ris
Fask masks should be worn by visitors and staff will
Control
remind visitors about hand hygiene
Current workload reviewed ‐ visits to be put on priority
Control
one, essential visits only
Control
Practice staff made aware of staffing issues
Community staffing running at unsafe levels. Staff reluctant to forgo annual
Action
Staff requested to take on extra shifts
leave as have previously done this in the pandemic. Currently 4 complex
Action
Bank shifts put out
patients on caseload in Peebles all with syringe drivers requiring lengthy
Primary &
Possible (3 May
Control
Marie Curie contacted for staffing support
reviews. 1‐2 trained members of staff working in each area ‐ no capacity to
Medium No escalation Medium
Managed
Business as
1850
Community
occur
Moderate (3)
assist each other as often 6 staff only working across locality. Increasing
(9)
expected
(6)
Shielding staff reviewed with occupational health support
(Treat)
usual
Services
occassionally)
Action
pressure on community nursing workload from GPS and consultants which
to assess ability to return to work
community staff cannot meet due to situation. High levels of staff within the
team ‐ risk of increased sickness.
Staffing reviewed and relocated on daily basis as per
Control
needs of service and skill mix requirements
Control
Staffing support across localities requested
Control
Advise from public health to use PPE within department
Advise from Infection Control on what is appropriate PPE
Control
to use
For staff unable to wear PPE within kitchens, alternative
Action
job role to be considered
Action
Risk to be raised at BET huddle
Action
Risk to be raised at Gold Command
OH referrals to be undertaken urgently for staff unable to
Action
wear masks
NHS Guidance for PPE within catering facilities to be
Action
made available
Catering kitchen staff are unable to socially distance due to job
Action
Explore if screens could reduce risk within kitchen setting
requirements.
Possible (3 May
Explore the option of taking staff temperatures at start of
Medium No escalation Medium
Action
Managed
1884
Support Services
occur
Moderate (3)
shifts
Safety
Some staff working are unable to wear masks, and as such may require to be
(9)
expected
(4)
(Treat)
occassionally)
Business continuity plan in place should staffing levels be
relocated to a different role for their safety impacting on staffing levels
Control
depleted
within catering department.
Discussion around option for shift work with HR, Public
Action
Health, Infection Control, H&S as part of continuity plan
Action
Toolbox talks to be undertaken by H&S
Control
Textured food pre‐made and delivered
Control
Sandwiches supplied by external provider
Control
PPE being worn by staff
Control
OH support for staff
Heat within department for staff in PPE will require to be
Action
monitored to ensure staff well being/ hydration/ regular
breaks
Continue to record adverse events including PPE related
Control
events
Control
Occupational Health support to all staff
13
COVID‐19 Risk Register
As at 29.09.2020.
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Likelihood
ns
Ris
o
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C
Co
Actions
ris
Ensure daily situational updates sent to all staff via
Control
COVID19 update
COVID‐19 threatens all operations as a result of its potential impact on duty
Here4U emotional support (drop in sessions, telephone
of care and staff wellbeing.
Control
and online chats) staffed by Psychology, Occupational
Health Nurses and Counsellors
There is a potential for staff to contract the virus resulting in a rise in
absences across NHS Borders and impacting on the staffing levels within
Creation of wobble rooms, enabling staff to find some
Control
services. Specialist services may not be able to fill these gaps.
quiet time during their working day
Control
Free access to Wellbeing Apps
Staff become overwhelmed/anxious impacting on mental health and
Control
Covid microsite and FAQs regularly updated
emotional wellbeing.
Control
Training for staff being deployed from other areas
Staff deployed into new areas may require additional support.
Likely (4 Strong
Control
Refreshment trolleys located throughout organisation
Medium No escalation Medium
Managed
1720 Organisational wide
possibility that
Minor (2)
Wellbeing
Increased concern from staff about contracting the virus/ vulnerable family
(8)
expected
(4)
Practical advice available on microsite including
(Treat)
this could occur)
members.
Control
information around childcare, accommodation, financial,
transport etc
Traumatic bereavement of family members could impact on staff wellbeing.
NHSB is engaged with the National Recruitment Portal,
organised by NES, and through this has deployed 2nd and
Change from business as usual, rapid change throughout organisation can
Control
3rd Year Nursing Students and FY1 doctors to augment
impact on the mental health of staff.
local services
Emotional impact of caring for sick and dying patients.
Bank Workers and Volunteers on stand‐by should clinical
Control
activity levels increase substantially
Staff working alternative hours/overtime.
In an attempt to minimise transmission, staff are
Control
encouraged to engage in appropriate social distancing,
good hand hygiene and to isolate where necessary
Control
Continual monitoring of bed occupancy
Control
Option to stop urgent surgery if required
Continue to monitor actual demand against a daily
updated model and trajectories on a daily basis so that
Control
we can quickly assess if this is diverging from the
ITU capacity for patients currently sits as 20 beds. Potential for capacity to
expected rate
be reached with introduction of vertical lists being reintroduced for urgent
Use of a private hospital in Edinburgh for high priority
Unlikely (2 Not
Control
surgery.
Medium
Medium
elective cases
Managed
1715
Acute
expected to
Major (4)
High
ITU capacity
(8)
(6)
Trigger points in place; when demand for general hospital
(Treat)
happen)
Current occupancy rates low. Daily modelling does not indicate that this will
Control
beds is at 100 and separately when ITU bed demand is at
increase above capacity.
13
Request mutual aid from other Health Boards or Scottish
Control
Government assistance if required.
Agree matrix to stop vertical booking (decision by
Action
01.05.20)
Action
Review anaesthetic staffing resources
Control
Local guidance follows Resuscitation Council UK guidance
14
COVID‐19 Risk Register
As at 29.09.2020.
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C
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Actions
ris
Do not undertake chest compression/airway procedures
Control
without appropriate PPE in situ
Control
Dissemination of guidance to staff and GPs
Patients with COVID‐19 who suffer a cardiac arrest will be offered CPR
Endorsed by NHS Borders aneasthetics Department and
Control
following guidelines where staff in hopsitals and GP or GDP practice settings
ITU staff
must be wearing full PPE in order to apply chest compressions or undertake
Full anticipatory care planning for early detection of
airway procedures. The guidance permits staff to trigger a 2222 or 999 call
acutely ill patients with Covid‐19 to avoid unnecessary
and to defibrillate patients with shockable rhythms before donning PPE but
Control
resuscitation attempts and identify those at risk of acute
they must wear level 3 PPE prior to undertaking chest compressions or
deterioration and cardiac arrest
airway procedures. There is a potential for patients to experience an
additional delay in receiving CPR whilst staff put on the higher‐level of PPE,
Review and approval at NHS Borders Ethics Support
Control
which may result in higher mortality. This is balanced by the lower risks to
Group
Unlikely (2 Not
key staff undertaking CPR who would otherwise be subject to potentially
Medium No escalation Medium
Business as
1723 Organisational wide
expected to
Major (4)
Face fit testing of all registered nurses and HCSWs in
Tolerate
higher viral loads if using lower‐level PPE for chest compressions. Based on
(8)
expected
(8)
Action
usual
happen)
community hospitals, Huntlyburn and East Brig
the current level of risk from COVID in the community setting community
staff coming across an arrest in the general community or whilst attending a
Action
Face fit testing of all GPs
patients home must call 999, if access to a community defibrillator is in the
Paper justifying decisions in relation to each pathway to
Action
near vicinity staff can administer defibrillation and commence chest
be presented to BET for approval
compressions only CPR using full PPE. If full PPE is not immediately available
Agreement from GPs that they will attend health board
HCWs must as minimum wear standard PPE including a fluid resistant mask
Action
outpatient clinics if cardiac arrest occurs in outpatient
and provide chest compression only CPR ensuring a covering or fluid
setting
resistant mask is placed across the patients mouth, as recommended by the
Action
Discuss at Board Clinical Governance Committee
Resuscitation Council UK, guidance for first aid and community settings.
Action
Discuss at NHS Borders Board
Advise community staff of appropriate precautions in
Control
event that they choose to carry out chest compressions in
line with Resus Council UK
Control
Daily staff update via C19 newsletter
Communications team central point for all information
Control
coming from NHS Borders
Social media posts monitored and investigate any
Control
complaints made
Negative press published can impact on the reputation of NHS Borders.
Ensure public informed of NHS Borders official
Control
Social media posts influence public perception and anxiety by amplifying
information as required
negative press/ personal experiences/ opinions.
Control
Daily report to journalists
Decisions made at Scottish Government level could adversely impact public
Control
Regular media briefings and interviews
perception at a local level (e.g. PPE).
Agreed program in place for social media posts from NHS
Control
Information available to the public on a UK national level may not reflect
Likely (4 Strong
Borders
Medium No escalation Medium
Managed
1725 Organisational wide
local situation.
possibility that
Minor (2)
Reputational
(8)
expected
(4)
Ensure NHS Borders promotes services still running/
(Treat)
Impact of people's reaction to COVID‐19 has potentially reduced
this could occur)
Control
attending A&E if n need of urgent medical assistance
presentations in A&E.
Staff are misinformed/ do not understand the information received.
Engage twice weekly with Scottish Government and
Fake news being spread through social media outlets can have a detrimental
Control
Heads of Communication for NHS Scotland to discuss any
effect on the public's opinion of NHS Borders.
issues
Control
Report fake news to media outlets
15
COVID‐19 Risk Register
As at 29.09.2020.
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C
Co
Actions
ris
Increase in interactions with public to ensure the correct
Control
information is being distributed
Action
Issue information on recovery plan to staff
Ensure public aware of service arrangements in recovery
Action
period
Infection Prevention and Control measures being adopted
Test and Protect programme leads to practice closure. Should a member of
Control
Primary &
Unlikely (2 Not
within primary care
staff be positive for Covid‐19 in one of the primary care practices, and staff
Medium
Medium
Managed
Business as
1847
Community
expected to
Major (4)
High
Control
Social distancing
in the practice are advised to self‐isolate, then there is a risk that the
(8)
(4)
(Treat)
usual
Services
happen)
Control
Liaison with local public health team
practice will need to close.
Action
Develop contingency plan
Clinicians reviewing list and contacting patients via
Control
Increasing patient waits for routine Outpatient and Inpatient/Day Case
telephone or Near Me consultations to
appointments. In light of the COVID restrictions imposed on the country,
Likely (4 Strong
Re‐categorisation of patients on waiting lists in order of
NHS Borders has suspended routine outpatient clinics and operations. This
Medium No escalation Medium
Control
Business as
1848
Acute
possibility that
Minor (2)
potentially worsening conditions.
Tolerate
has resulted in increasing waits for these patients and an increasing number
(8)
expected
(8)
usual
this could occur)
Urgent and Cancer appointments and surgery continuing
of patients breaching their outpatient 12 week target and surgical
Control
and adequate capacity allocated
Treatment Time Guarantee dates.
Recovery plans underway to re‐start routine clinical
Action
capacity to reduce waits
Clinical risk associated to reduced patient access to primary care. There is a
GPs have continued to manage their demand throughout
risk that the reduced demand for primary care services, and the reduced
Control
the pandemic and have prioritised urgent cases
Primary &
access including:
Unlikely (2 Not
Medium No escalation Medium
Business as
1849
Community
‐ use of virtual consultation (telephone /Near Me assessment) in GP
expected to
Major (4)
Emergency Dental and Eye Care Treatment Centres have
Tolerate
(8)
expected
(8)
Control
usual
Services
practices
happen)
managed emergency dental
‐ dentists and optometrists that were closed during the initial covid
Remobilisation of dental services and optometrists
Control
response leads to clinical risk to patients, including missed or delayed
reduces the likelihood of this risk
Control
Local daily modelling
Action
Order of more efficient ventilators
Downstream usage on oxygen where possible, including
Control
access to cylinder oxygen
Modifications to the oxygen plant that have been
Control
recommended to ensure the maximum distribution of
oxygen from it
Providing an adequate supply of oxygen per minute to meet predicted
Should the BGH approach the maximum delivery from
demand within the BGH. The key problem is the rate of oxygen flow into
our plant then we would be seeking urgent discussions
the piped supply may be insufficient in response to demand from COVID
Action
regionally / nationally to consider transporting Borders
patients.
patient to other facilities before compromising the care of
Capacity dependent on volume and acuity of patients receiving oxygen
Unlikely (2 Not
Medium
Medium
patients within the BGH
1717 Organisational wide
supply.
expected to
Major (4)
High
Tolerate
Oxygen
(8)
(8)
Using adapted anaesthetic machines to support ITU patients require high
happen)
Patients on low‐flow oxygen are supported with the
flows of oxygen, require soda lime and have a large footprint for a small bed
Control
cylinders rather than putting additional demand on the
space. In the absence of further new ventilators we will be required to
piped supply
continue using the adapted machines noting their limitations.
RHSC Edinburgh donated 4 anaesthetic machines that are
Control
oxygen efficient and have high ITU quality ventilators
Escalation procedure based on oxygen usage trigger
Control
points in place
16
COVID‐19 Risk Register
As at 29.09.2020.
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C
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ris
Control
Audit of oxygen usage carried out across NHS Borders
Close monitoring of flow rates and usage implemented to
Control
control risk
Home for Hearing Screening Programme
Area with safe space located within main outpatient area
Since the start of COVID escalations, the location of the neonatal hearing
Control
to carryout the clinic and to continue the service
screening programme service was moved to Newstead (occupational
health). The newborn hearing screeners have now been asked to move out
Estates staff are monitoring the clinic to ensure safety of
Control
of Newstead as occupational health return to seeing patients and the
staff
Possible (3 May
hearing screener are left without a location to undertake their screening
Medium No escalation Medium
PPE in line with national guidance is in use by staff
Managed
1866
Acute
occur
Minor (2)
Control
Safety
programme ‐
(6)
expected
(4)
members
(Treat)
occassionally)
We therefore propose to commence our programme using available space
Liaison with national programme leads to ensure out
Control
in outpatients A on a Saturday morning.
service remains equitable with others within Scotland
This space is available and we have staff from our service are also available
Pathway has been agreed with NHS Lothian for our
at this time, but risks include lone working in the department at this time
Control
patients from NHS Borders
while no other services are running.
Action
Staff need to follow telemetry protocol
Need to review all patients daily as minimum re: need to
Action
contine on telemetry and remove if clinically safe to
discontinue
Nursing staff must follow telemetry review process &
Action
document
Medical staff to ensure daily review re: ongoing need for
Action
telemetry
Use advice of cardiac nurse specialists if unsure / unclear
Action
telemetry required / can be removed
Staff to remove timely when identified as no longer
Unlikely (2 Not
Action
needed and highlight to Site & Capacity, patient can then
Temporary reduction of available downstream telemetry beds during Ward
Medium
Managed
1872
Acute
expected to
Moderate (3)
Low (1)
downstream
Safety
4 decant to CV4 (Ward 12) ‐ 10.08.20 to 16.09.20 ‐ 21.09.20 (latest)
(6)
(Treat)
happen)
Ward 5 / MAU to add to Safety Brief to highlight issue if
Action
unable to remove telemetry
There will likely be a need to rview patients telemetry use
Action
overnight to identify possible downstream patients ‐
Nursing / medical / HAN team to review each night
Patients should not be admitted to Ward 5 unless they
Action
require monitoring or HDU level care
Patinets who are suitable to be discharged from Ward 5
Action
to a downstream ward without ongoing monitoring
should be prioritised for downstream beds
Transport Hub risks associated to role of transporting COVID‐19 positive or
Control
Safe system of work
suspected positive patients to and from the Covid Assessment
Control
Infection control training
17
COVID‐19 Risk Register
As at 29.09.2020.
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C
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Actions
ris
Centres;Patients being discharged from ED1 (suspected Covid) and
Masks can be removed for journey home if journey has
discharges from Covid wards; Transportation of Dialysis Patients previously
Control
been an hour as long as windows are open
carried by volunteer drivers; Delivery of COVID‐19 swab tests to NHS Lothian
and Glasgow; Delivery of Cytotoxic Drugs (Chemotherapy) to patient
Control
Appropriate PPE utilised
homes; Co‐ordination of Community Pharmacy prescription deliveries by
Control
PPE training for all staff
Control
Training on cleaning
Borders College to patient ; Delivery of doorstep COVID‐19 test kits;
Control
PMAV advice and support
Transportation of patients to and from emergency dental and optometrist
Control
Mobile phones available to staff
centres; Transportation of equipment for Covid patients and where capacity
Control
Occupational Health support
allows, provide transport for some non‐COVID discharged BGH patients.
Control
Supervision
Risks:
Possible (3 May
When in vehicle with bulkhead, driver on own in front
Medium No escalation Medium
1707 Organisational wide
1. Vehicles:
occur
Minor (2)
Control
and does not need to wear PPE unless accompanied by
Tolerate
Safety
1.1 Vehicles not meeting national standards
(6)
expected
(6)
occassionally)
HCSW in front of vehicle. As per HPS guidance
1.2 Cleaned correctly in line with national and local infection
Control
Transport Hub SOPs
control guidance to prevent cross contamination
1.3 Used for appropriate patient groups (Covid +/suspected and non
Control
Mobile Phones issued for each transport hub car
covid) to prevent cross contamination
Control
SatNavs in each car
1.4 correct storage and maintenance of vehicles so available for
Control
Use of safe shores system
transportation of patients
1.5 Emergency procedures should anyone become ill, if in an
Passengers which are not known to the organisation
Control
accident, vehicle fault or run out of fuel
transported in vehicle with bulkhead
1.6 Staff safety as drive through testing
Control
Vehicles split into Covid and non covid use where possible
2. Drivers and passengers:
Use Red Box UNN 3373 clipped travel plastic boxes to
2.1 Exposure to covid‐19 and other viruses/diseases, PMAV,staff
Control
transport swabs
Due to COVID 19 redeployment measures
i t
the health visiting service
Control
Management monitoring staffing levels
Primary &
Unlikely (2 Not
workforce is reduced as the team are supporting testing.
Medium No escalation
Managed
Business as
1722
Community
expected to
Moderate (3)
Low (3)
Action
Weekly monitoring of situation by management
Children are at increased risk of physical, emotional, sexual harm and
(6)
expected
(Treat)
usual
Services
happen)
neglect during COVID restrictions. Domestic abuse and child protection
Control
Follow Scottish Government guidance
All patients during the community transmission phase of
COVID‐19 pandemic are escorted individually from their
transport/vehicle into the building by appropriately
protected staff. Patients remain in their vehicles in
Control
specific ‘coned’ areas of car park until staff member
meets them. Patients are provided with a FSFM to wear
prior to entering the building. Patients entering and
leaving do not come into contact with any other patients
Patients currently access the dental centres via the front door passing
Primary &
Unlikely (2 Not
as flow is strictly monitored.
reception. This increases the risk of cross infection and also increases chance
Medium No escalation
Managed
Business as
1721
Community
expected to
Minor (2)
Low (2)
of interaction with others and risking passing the infection to others.
(4)
expected
(Treat)
usual
Services
happen)
Patients seen by invitation only after thorough telephone
triage. Front door/public access locked with appropriate
Control
signage asking patients to telephone dental enquiry line.
Staff entering via different access to patients.
18
COVID‐19 Risk Register
As at 29.09.2020.
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Likelihood
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C
Co
Actions
ris
Telephone triage according to national guidance reducing
Control
the requirement for patients to attend dental centres.
Control
Separate surgeries for AGP and non‐AGP dental care.
Lack of speciality footprint within the Acute site. Provision of specialty
Unlikely (2 Not
Medium
Medium
Managed
1761
Acute
specific care may not occur leading to adverse events, increased length of
expected to
Minor (2)
High
Action
Bed plan factors in when speciality wards can re‐open
Safety
(4)
(9)
(Treat)
stay, lack of continuity of care and poor patient experience.
happen)
Control
Monitor staffing levels
National guidance to have nurse ratios of no lower than 1 ITU trained nurse
Patient: Nursing ratio 1:1, however, due to there being
per 6 patients with other staff making up a total ratio of 1:2 and a
Unlikely (2 Not
Control
half ITU trained nurses and half non‐trained ITU staff then
supervising nurse in charge. At this level care will be significantly lower than
1718
Acute
expected to
Negligible (1)
Low (2)
High
Low (2)
patient: trained staff ratio is 1:2.
Tolerate
Workforce
normal and there is a risk that patients may come to serious harm or death.
happen)
Staffing from the intensive care nurse workforce for long as the demand for
Patient levels in ITU are back to normal, however, if there
them in intensive care will increase and this is a finite workforce resource.
Action
is a second peak of Covid then the plans would be
brought back.
19