CORPORATE RISK REGISTER & ASSURANCE FRAMEWORK

Transcription

1 CORPORATE RISK REGISTER & ASSURANCE FRAEWORK BRIEFING NOTE PREPARED FOR TRUST BOARD 7 SEPTEBER 2017 There are 26 risks on he as anagemen Team eeing on 10 h Augus Noe 771 is pending de-escalaion whils awaiing confirmaion ha i is now on all relevan direcorae regisers. aerial changes o for approval There are no maerial changes for consideraion a his meeing. 1

2 Iniial Curren Targe Assurance Framework as a 07 Augus HIGH 12 HIGH 12 EDIU edical ae Governa nwor kfor Tile Descripion Conrols Assurance Gaps in conrols Assurance Assurance Gaps in assurance Due dae for Healh and Safey risk - resuling in injury of injury o paiens/cliens/saff and visiors arising from failure o fully comply wih Healh & Safey legislaion. Inciden reporing and invesigaion. Healh & Safey Inspecions and acion plans. Inducion and andaory Training for Saff. Occupaional Healh Self and anagemen Referrals. Use of aids e.g. hi-lo beds, hoiss. Paien/clien risk assessmen. Leadership Walk rounds. KPI for healh & safey, e.g. falls. Falls Assessmen. Falls Prevenion Policy. Labs represenaive on Healh & Safey Working Group anager and anagemen Officer NEBOSH qualified in addiion o H&S officer COSHH added as sanding iem o Healh &Safey Working Group agenda. Annual review of compleed H&S Assessmens ae Gov Repors wih H&S RA info Healh & Safey Policy. Healh & Safey Working Group. H&S Assessmens. Specific healh & safey policies (e.g. COSHH, Laex, anual Handling, Firs Aid). Nominaed Sie (Fire, Healh & Safey) Officer raining. Trus Groups dealing wih specific H&S issues, e.g. Securiy, Fire, Radiaion Proecion. Noificaion of Counsel's advice re EL/OL claims. Lack of funding o purchase H&S equipmen or underake mainenance of equipmen/faciliies. Comparaively limied saff resources dedicaed o H&S. RQIA inspecions. Inernal Audi of H&S Conrols Assurance Sandard (2012/13). Benchmarking by Regional H&S Praciioners Group. Inspecions by HSENI. Inspecions by H&S Officer and H&S Working Group members. Review of Inciden daa by H&S Working Group (inc. Union reps). Inspecions by Regional edical Physics Advisers. Sharepoin sie for H&S Assessmens. Inernal Audi of anagemen Conrols Assurance Sandard (2013/2014). anual Handling Audi a Alnagelvin Hospial (July 2013 and re-audi Sepember 2014) onioring of implemenaion of recommendaions following inspecions/leadership walk rounds. BSO Inernal Audi of H&S (June 2014). Labs o be represened on 31/01/2017 Healh & Safey Working Group 30/11/2017 Developmen of H&S learning 28/02/2017 hemes for Claims, Incidens 28/02/2017 and Complains o evidence acions required. anagemen Officer rained in NEBOSH o complee shadowing of H&S Officer and carry ou firs H&S Inspecion. anager o complee NEBOSH qualificaion. Prioriy raionale for H&S Inspecion Carry ou review of compleed H&S Assessmens. 09/01/ /02/ /02/ EXTR E 25 EXTRE 9 EDIU of Childrens Children's Unallocaed Cases - Poenial for harm o children whils awaiing Childcare Gaeway and Family Inervenion Service (unallocaed cases) due o capaciy issues in he service limiing he abiliy o respond in designaed imescales. Ongoing acion o secure recurring funding. FGC Service conacs FIS o organise FGCs o reduce risk / aemp early resoluion. Looked Afer Service reviewing capaciy o enable ransfer of cases. Updae meeings beween F&CC ADs and. e anagemen Review is being underaken by HSCB wih all 5 Truss focusing on Unallocaed cases and imescales Senior g closely monioring, saff redeployed emporarily unil full complemen of saff in Enniskillen can be recruied Senior anagemen have been closely monioring he siuaion and effors have been made o recrui addiional saff, due o he difficuly in recruimen, some saff from oher eams have agreed o be redeployed in he inerim unil he full complemen of saff can be in pla Temporary redeploymen of saff Service and SW anagers consanly prioriise workloads. Inabiliy o recrui saff in Enniskillen area Quarerly governance repors o No gaps idenified Governance Commiee. Feedback given o e & Service for accounabiliy meeings wih HSCB. Up-daes by o CT and Trus. redesigning some service areas which will address some of he unallocaed cases issue so his will be reviewed again when he new arrangemens are in place Saff redeployed emporarily o Enniskillen area unil saff recruied 30/09/2016 Page 1 of 10

3 Iniial Curren Targe Assurance Framework as a 07 Augus HIGH 12 HIGH 8 HIGH edical ae Governa n Tile Descripion Conrols Assurance Gaps in conrols Assurance Assurance Gaps in assurance Due dae for Lack of cross- ae learning from adverse incidens, complains, claims & audi recommendaions Poenial risk ha learning from incidens, complains, liigaion and audi is no disseminaed across he organisaion, or regionally across he HSC. Repors o Senior anagers re closed incidens. Share o Learn newsleer and Lesson of he Week. Use of Daix o record lessons learned and provision of repors. Quarerly Audi Up-daes o aes. Audi Seering Group. Annual Audi Conferen Deails of Audis carried ou independenly by saff are provided o Audi Dep. Role of CT/Governance Commiee/Trus Board. Learning Leers issued by HSCB. Communicaion of learning arising from incidens, SAIs, complains and legal claims and associaed acion plans. Qualiy Even SAI Learning Even Claims learning hemes developed Daix upgraded o maximise poenial of sysem Compliance wih Regional Pos Falls Review and Learning emplae - Now on Daix Sandard learning repors on Daix for Daixweb users o produce heir own learning Learning from Audis ha are carried ou wihou knowledge of Audi Deparmen may no be implemened. No regionally agreed process for sharing learning following legal claims (o be developed by ae of Legal ). No sysem for providing assurance ha learning idenified has been shared and pracice changed. Learning hemes no ye applied which could focus acion on broad areas for improvemen Auomaic Daix feedback funcion o reporer onhly repors o HSCB on closed complains. Inspecion by RQIA. BSO Audi of anagemen and Governance Conrols Assurance Sandards. BSO Audi of anagemen Procedures (yearly). Exernal audi (NIAO). Audi of Junior Docor Incidens (January 2013). BSO Audi of Claims anagemen (Ocober 2014). BSO Audi of Healh & Safey (June 2014). BSO Audi of Inciden Reporing Procedures (February 2012). DHSSPSNI/RQIA Review of SAIs BSO Audi of complains Idenificaion of learning hemes 30/11/2017 and allocaion of hese o SAIs 31/01/2017 and liigaion 31/12/2016 Upgrade Daix o faciliae Auomaic Daix feedback Roll ou of sandard learning repors on Daix Learning Themes developed for Liigaion cases Falls learning emplae sysem adoped Auomaed o reporers wih Learning from incidens hrough Daix upgrade 15/02/ /11/ /02/ EXTR E 12 HIGH 8 HIGH edical Governa npubl ic Confidenc e.workfo r Failure o mainain he qualiy of services delivered of Harm o Paiens or Cliens as a resul of qualiy of care provided. Upgraded Daix sysem onioring of and risk escalaion process. edical Appraisal. Review of Incidens/SAIs/Complains & Claims. Trus Qualiy Sraegy. Qualiy Plan under Paien Safey Programme. Inciden Reporing Policy. Whisleblowing Policy. Repors o Trus Board/Governance Commiee. Senior saff rained in Roo Cause Analysis. ae quarerly repors provided. Saff raining. SAI Learning Even Dependence on locum saff - awareness of inciden policy. RCA Training package o be reviewed and raining provided RQIA inspecions and reviews (e.g. review of SAIs repored ). Donaldson Review. Professional Audi. Audi of Incidens involving Junior Docors. edical 's Annual Appraisal Repor. ae Repors o Governance Commiee. Inernal Audi, e.g. Governance, anagemen, Inciden Reporing, Claims anagemen and Healh & Safey. ae quarerly repors provided. RQIA review of Learning from incidens awaied Dependence on locum saff - awareness of inciden policy. Developmen of learning hemes for Claims, Incidens and Complains o evidence acions required. RCA raining o be revised Daix sysem upgrade Inciden reporing policy o be revised. 30/11/ /10/ /01/ /10/ /02/ EXTR E 25 EXTRE 9 EDIU of Childrens Children's Unallocaed Cases - Poenial for harm o children whils awaiing Childcare Gaeway and Family Inervenion Service (unallocaed cases) due o capaciy issues in he service limiing he abiliy o respond in designaed imescales. Ongoing acion o secure recurring funding. FGC Service conacs FIS o organise FGCs o reduce risk / aemp early resoluion. Looked Afer Service reviewing capaciy o enable ransfer of cases. Updae meeings beween F&CC ADs and. e anagemen Review is being underaken by HSCB wih all 5 Truss focusing on Unallocaed cases and imescales Senior g closely monioring, saff redeployed emporarily unil full complemen of saff in Enniskillen can be recruied Senior anagemen have been closely monioring he siuaion and effors have been made o recrui addiional saff, due o he difficuly in recruimen, some saff from oher eams have agreed o be redeployed in he inerim unil he full complemen of saff can be in pla Temporary redeploymen of saff Service and SW anagers consanly prioriise workloads. Inabiliy o recrui saff in Enniskillen area Quarerly governance repors o No gaps idenified Governance Commiee. Feedback given o e & Service for accounabiliy meeings wih HSCB. Up-daes by o CT and Trus. redesigning some service areas which will address some of he unallocaed cases issue so his will be reviewed again when he new arrangemens are in place Saff redeployed emporarily o Enniskillen area unil saff recruied 30/09/2016 Page 2 of 10

4 Iniial Curren Targe Assurance Framework as a 07 Augus HIGH 12 HIGH 9 EDIU of Human Resources ae Challenges o compliance wih Working Time Regulaions Tile Descripion Conrols Assurance Gaps in conrols Assurance Assurance Gaps in assurance Due dae for For Junior Docors in raining he Trus may no be able o fulfil is sauory obligaions under he EWTD and/or New Deal due o he inensiy of junior docors roa or lack of docors paricipaing on he roas and/or an inabiliy of he Trus o fill vacan poss by recruimen or agency. Docors on full shif roas and on call roas may exceed he maximum 48 hours of acual work hus breaching he maximum hours requiremen under EWTD. This may also pu he roa ino a higher Banding Supplemen. In paricular he unpredicabiliy of on call roas means ha 11 hours coninuous res (or compensaory res) in every 24 hour period may no be achieved. "Sleep-in" is a working paern in residenial faciliies where a member of saff is required o sleep in he faciliy as a back up o waking nigh duy saff. Sleep may be disruped due o cerain siuaions so compensaory res is allocaed. Home Care saff who have conraced working hours in excess of 30 hours per week and Home Help saff whose regular caseload exceed 30 hours may mean ha on occasions heir shif paern does no mee daily res requiremens under EWTD. onioring of Junior Docors working hours. Represenaions made o BLG & NTA regarding abiliy o susain roas. Payroll alers o HR on excessive working hours. ae Suppor Team working wih W&C ae o address siuaion in Residenial Children's Homes. Bi-annual monioring of hours o deermine Junior Docor workload repored o DOH. Ensure compliance wih Locum agency conrac arrangemens. Guidance on EWTD and compensaory res. AD HR member of Regional edical and Terms & Condiions Group. Leer sen o Nursing saff in Acue & AHLD Dirs in July 2013 and PCOP in Oc reminding hem of requiremens of EWTD. Senior HR anagers are assessing he consisency of approach in relaion o sleep ins across he Trus. Guidelines o clarify bank arrangemens developed (QICR2). Agreemen o phase ou use of Home Care/Home Help high hour conracs. Trus paricipaion on Regional Working Group o review roa for Children's Homes. Inabiliy of NTA o fill all poss. Despie bes effors he Trus is no always able o mee he requiremens of he regulaions. Junior Docors monioring informaion submied o DOH and considered by Board Liaison Group. HSCB, hrough Board Liaison Group, monior safe hours of work for Junior Docors and Deniss. Work coninues wihin relevan aes in relaion o roas, sleep ins, ec. Reissue of leer o nursing saff regarding EWTD responsibiliies. Review of Guidance on EWTD and compensaory res. 31/03/ /12/ /12/ HIGH 16 HIGH 9 EDIU of Virus aack disables nework/services Informaion securiy across he HSC is of Daa & Sysem backups criical imporance o delivery of care, 3rd Secure Remoe Access proecion of informaion asses and many Server / Clien paching relaed business processes. If a Cyber HSC securiy sofware (hrea deecion, inciden should occur, wihou effecive anivirus, and web filering) securiy and conrols, HSC informaion, HSC securiy hardware (e.g. firewalls) sysems and infrasrucure may become 3rd Pary Conracs / Daa access agreemens unreliable, no accessible when required Conrac of employmen (emporarily or permanenly), or compromised HR Disciplinary Policy by unauhorised 3rd paries including andaory raining policies criminals. Inducion policy This could resul in unparalleled HSC-Wide Regional and local Inciden anagemen & disrupion of services due o lack reporing policies & procedures of/unavailabiliy of sysems ha faciliae HSC anagemen framework, services (e.g. appoinmens, admissions o Processes & monioring hospial, ED aendance) or daa conained Emergency planning & Service business wihin. This may resul in he need o cancel coninuiy plans appoinmens and reamens, or diver Disaser recovery plan emergency/essenial clinical or oher services. Ussr accoun managemen processes The significan business disrupion could also Change conrol processes lead o increased waiing liss, delayed urgen Daa proecion Ac clinical inervenions, subopimal clinical Regional & Local ICT info securiy policies oucomes and poenially bring liabiliies for he Servi I could also lead o unauhorised access o any of our sysems or informaion (including clinical/medical sysems), hef of informaion or finances, breach of sauory obligaions, subsanial fines and significan repuaional damage. Insufficien User Awareness of impac of personal behaviours in relaion o cyber hrea Full exen of gaps are no undersood a his poin - Gap analysis regionally and locally required by HSC o capure a considered exen of vulnerabiliies Insufficien corporae recogniion and ownership of cyber securiy hrea as a service delivery risk HSC SIRO Forum for shared learning and collaboraive acion planning and delivery Inernal audi / IT Dep. selfassessmen agains 10 Seps owards NCSC Technical risks assessmens and peneraion ess Plan "faux" cyber securiy 31/12/2017 exercises o es user 31/03/2018 behaviours, service coninuiy / 31/08/2017 disaser recovery plans and ake 31/08/2017 appropriae acions in ligh of 31/12/2017 consequences and learning 30/11/2017 Work wih colleagues across he 30/11/2017 region o develop and share learning, echniques, proocols and saff guidance, including User Awareness Campaign and Sysem anagers/admin raining Inroduce rouine reporing o Trus Board (or oher equivalens (local or regional)) on repored incidens/near miss, and oher agreed indicaors Revisi Business Coninuiy Planning wihin conex of widescale local & regional service disrupion during a poenial cyber securiy inciden Develop a Cyber Securiy Sraegy and o address he mos significan areas of risk idenified, focusing on srenghening governance & policy, improving process & educaion, invesing ime and resources on Cyber Inelligence and monioring. Carry ou risk assessmen of he Page 3 of 10

5 Iniial Curren Targe Assurance Framework as a 07 Augus HIGH 16 HIGH 8 HIGH of Finance ae Finance and Conracing Financial anagem en & Tile Descripion Conrols Assurance Gaps in conrols Assurance Assurance Gaps in assurance Due dae for The inabiliy of he Trus o achieve break-even for 2017/18 The Trus has quanified is opening defici a 40m and has idenified addiional in-year cos pressures amouning o 19m. The Trus is awaiing confirmaion of he funding o be expeced for 2017/18 and discussions are coninuing wih he DoH. onhly review by of Finance of ongoing applicabiliy of accouning assumpions and esimaes. anagemen Team Financial onioring Group monior performance reporing o Trus Board as well as achievemen of savings arges. Escalaion process for flagging significan issues o he Chief Execuive. ae Accounabiliy meeings cover performance agains financial arges. Developmen of coningency plans o suppor delivery of breakeven. Regional Financial Sabiliy Board mees bimonhly. TYC Programme Board which moniors delivery of savings. onioring of Acion plan by HSCB/DOH Conrols are in pla CTFG financial performance However, i is no repors o Trus Board and CT always possible o have members. full financial conrols DHSSPS/HSCB monhly financial wihou looking a monioring. qualiy & safey risks o Exernal Audi (NIAO). paiens/cliens. Self-assessmen and audi of Financial anagemen Conrols Assurance Sandard. Assurance obained by he Chief Execuive from chairing CTFG. Assurances from of Finance and ADF o CT & Trus Board. Inernal Audi EDIU 12 EDIU 9 EDIU of Human Resources Over dependence on he use of locum and agency saff o susain services and insufficien inducion for locum medical saff of inabiliy o mainain services as a resul of Trus wide difficulies regarding recruimen o cerain specialies across he Trus resuling in an over dependence on he use of agency and locum saff. (Also see Acue ae 344 and PCOPS 702). Implemenaion of Circular HSC (F) Inroducion of new axaion rules applying o off payroll working (IR35). Trus HR represenaion a regional AHP Group. Trus HR represenaion a Inernaional Nurse Recruimen Groups. Senior HR anager (Band 8a) edical Workforce Projec and QICR in pos. Roll ou of Erosering which means beer reporing on use of bank and agency saff by area, ward, ec. Procedure for IR35 Assessmen. edical Workforce Recruimen and Reform Projec Board. ae summary "yellow pages" informaion on Agency & Locum coss repored hrough QICR. Guidelines on use of medical and non-medical agency saff. Use of recognised employmen agencies o recrui Locums. Locum placemen assessmen form. Nursing Peripaeic Nursing Team. Preparaion & inducion of Locums o underake heir assigned roles. Professional Nurse Inerviewers. CVs verified by senior saff. Terms & Condiions of Conrac. Represenaions made o NTA regarding Jnr Dr requiremens. Insufficien applicans for nursing and social work poss. Inabiliy of NTA o provide required number of Junior Docors for cerain specialiies. Unpredicabiliy of circumsances i.e. o cover sick leave or an increase in demand for servi Progress repors o Audi on recommendaions. Audi Repor on anagemen of use of agency and medical locum saff. Lack of a regional cap Progress edical Workforce on agency raes. Recruimen & Reform Projec Plans Coninue o work on a regional on soluions. Address ad hoc specialiy issues as hey arise. 31/03/ /03/ /03/ EXTR E 15 EXTRE 15 EXTRE of Adul Adul enal enal Healh & Healh & Learning Disabiliy Disabiliy Governan High risk forensic/challengin g individuals who have poenial o cause harm o hemselves or ohers High risk forensic/challenging individuals who have a poenial o cause harm o hemselves or ohers. Ongoing Training and suppor o saff. Ongoing uli-agency monioring. Individual coningency plans in pla ulidisciplinary & muli-agency discharge review meeings. anagemen & supervision of regiser. Live regiser of hose who presen mos a risk. Keyworkers and Care Co-Ordinaors idenified for each Enhanced Discharge Plan. Limied herapeuic environmen. Lack of local availabiliy of low secure placemens or sepdown faciliies. Limied abiliy o ensure herapeuic inervenions. Specialis services generally no well resourced. RQIA inspecions/reviews. Low of incidens repored for his clien group. Review Enhanced Care plan lis by AH Governance lead 31/07/2017 Page 4 of 10

6 Iniial Curren Targe Assurance Framework as a 07 Augus HIGH 9 EDIU 6 EDIU of Childrens ae Tile Descripion Conrols Assurance Gaps in conrols Assurance Assurance Gaps in assurance Due dae for Availabiliy of age appropriae inpaien services for children and young people wih menal healh difficulies The placemen of an under 18 in an adul psychiaric ward is no appropriae due o age and need. All risks associaed wih such a placemen require individual aenion based on he needs of each siuaion. Admission o regional Tier 4 services are no always deemed o be herapeuically appropriae as families prefer o say in localiies. Requiremen for dedicaed, specialis CAHS service o underake assessmens ou of hours. Assessmen and Under-18 Admission Guidelines. Service Plan under TYC being implemened o assis in developmen of CAHS re-design in accordance wih Sepped Care odel. Pre-employmen veing of new saff who may come ino conac wih children. Inerim arrangemens wih AH ae wih regular inerface meeings o review/srenghen pracice and ransiions. Liaison wih he Commissioner re availabiliy of regional beds. New saff saring pos in Crisis Home Treamen. This will enhance abiliy o reduce under 18 admissions. onioring and reporing o HSCB of Trus posiion re Under-18 admissions. CAHS Redesign has been fully implemened. WHSCT OOH being reviewed o ensure effecive engagemen and assessmen OOH. The Trus has in place a proocol for "Admission, reamen and discharge of children and young persons under 18 o Adul Wards a Tyrone & Fermanagh, Grangewood and Lakeview Hospials." Quarerly repors o RQIA/HSCB re under 18 admissions o adul H wards. Veing of all saff on Adul Wards involved in he care of children and young persons no carried ou. Full implemenaion of Child Proecion Policy wihin Acue seings. Lack of Psychiaric Inensive Care Uni for Children and Young People in WH&SCT area. ae repors o Governance Commiee. RQIA Reviews. Inegraed Inensive Treamen for Teenagers service srenghened o adop a home reamen approach for young people o mainain hem in heir own homes hus prevening hospial admission. Audi has aken place on his maer and a repea audi is planned. Feedback from HSCB confirmed WH&SCT U18 admissions reporing process is good pracice and robus. The Trus have made a bid o he Commissioner (under demographics) for funding o provide a dedicaed CAHS Ou of Hours servi Inernal Audi of implemenaion of Under-18 Admissions Proocol. This o ake pla New proocol has no been in place long enough o be audied as ye (arch 2011) Proocol o be reviewed Annual Review of Under 18 Admissions o Aduls Wards TFH, Grangewood and Lakeview Developmen Day planned for 5/2/15 o commence implemenaion of recommendaions from Regional Review. 30/04/ /09/ EXTR E 20 EXTRE 12 HIGH of Financial Financial and anagem performance risk en & Demand for services exceeds commissioned volumes across a range of planned services. The increased s of Unscheduled/emergency demand/referrals in 2015/16 have resuled in increased pressure on a range of hospial, Older peoples, H and Childrens services. There is a financial risk associaed wih assuring paien safey, and miniserial arges for access o services will no be me as refleced in TDP. idenificaion and monioring via inciden reporing/saff supervision/hos meeings/weeklymonhly PFA onioring/managemen accouns repors/governance, ST/CT meeings. Engagemen wih Commissioner. Regional Access Crieria for Domiciliary Care. Crieria for Access o Nursing/Residenial Homes. ae and Trus Scruiny Process RQIA inspecions of regulaed services. DSF repor, clinical audi and repors o Trus Board, e repor o Trus Board monhly. Special Trus Board o furher 31/10/2016 consider TDP and savings plan proposals onhly review of financial expendiure repors and inciden repors EXTR E 10 HIGH 5 HIGH of Adul Adul enal enal Healh & Learning Disabiliy Healh & Disabiliy Deah or serious injury of paien as a resul of a suicide or aemped suicide while in a Trus faciliy Deah or serious injury of paien as a resul of self-harm, aemped or compleed suicide, while in a Trus faciliy. Close liaison wih nex-of-kin. Appropriae care plan, nursing and medical managemen. Ligaure assessed environmens. Trus Special observaion policy is applied Assessmen upon admission and regular review. Pre-discharge review and enhanced discharge plan. Collapsible Rails. Inducion of new saff ongoing. Review of a AH&D governance meeings. Serious Adverse Inciden invesigaions and disseminaion of learning. Regional AWOL policy is applied. Close liaison wih family & PSNI if paiens abscond. Policies, procedures and muli-disciplinary working. Saffing s reviewed o ensure paien safey. Lack of undersanding of policies and procedures of newly qualified saff. RQIA inspecions Regular Audi of Assessmen by Ward anagers. Donaldson Review and review of SAIs repored Review of Serious Adverse Inciden Repors by HSCB/RQIA. ainain regular review. Page 5 of 10

7 Iniial Curren Targe Assurance Framework as a 07 Augus HIGH 12 EDIU 6 EDIU of ae Governan Tile Descripion Conrols Assurance Gaps in conrols Assurance Assurance Gaps in assurance Due dae for ha paien medical records and/or paien informaion on Trus sysems may no be complee, accurae or available a PoC There is a risk ha he Trus will no mee is obligaions under GGR o manage and mainain records and is wider informaion asses appropriaely. There is a risk ha he qualiy and compleeness of daa on he Trus's sysems will no be o he required sandard. Informaion Governance Seering Group has an assurance role for he Trus. andaory raining on FOI and DPA. Roll ou of Elecronic Care Record wihin he Trus o enable elecronic availabiliy of summary medical record. Informaion Governance / Records anagemen awareness raining programme for IAOs. Develop Robus awareness raining programme. Need o develop formal process o remind saff of responsibiliies Level of mandaory raining up-ake by Trus saff falls well below he required/argeed. No dedicaed Daa Qualiy Team wihin he Trus o suppor he improvemen of daa qualiy/compleeness on Trus sysems. Inernal Audi of compliance wih GGR. Briefings o anagemen Sub- Commiee/Governance Commiee on significan issues. KPG review of Informaion anagemen CAS self assessmen. BSO Audi of Informaion anagemen CAS. Inernal Audi of Informaion anagemen CAS. Char spliing process developed and responsibiliies agreed. Poor up-ake of mandaory raining. Record-keeping issues a ward idenified by OPJ projec. is-filing of records a coninued issue as idenified hrough he checking of records required under SAR. edical records no sored, disposed of or reurn o libraries in line wih required proocols. The Trus received a parially limied assurance in he inernal audi of Informaion Governance, relaing o specific areas in he Trus. Acions have been agreed o address hese deficiencies. PSI o bring fwd proposal o esablish Daa Qualiy Team wihin he Trus. RF projec roll ou. 30/06/ HIGH 15 HIGH 9 EDIU of Trus Emergency Plans Failure o effecively implemen he Trus Emergency Plans and Call-ou Schedule could lead o a ineffecive response o a major inciden which could resul in serious injury or deah o paiens/cliens or saff and loss of servi Fire Evacuaion Plans for all faciliies. Trus paricipaion in live and desk-op exercises. Hospial Lockdown Plan in place for Alnagelvin and SWAH. ass Prophylaxis Plan. Trus ajor Emergency Plan. ajor inciden plan for Regional Agencies PHA and RSCB. Emergency Planning Officer. Emergency Planning & Business Coninuiy Sraegic Forum. Trus represenaion on Regional Emergency Planning Forum. Learning from exercises incorporaed in he ajor Emergency Plan. Training and awareness programme. Deparmenal Plans require review / furher developmen Trus Wide. No risk assessmens performed. Emergency Planning Conrols Assurance Sandard selfassessmen. BSO Audi of Emergency Planning Conrols Assurance Sandard. Annual repors o HSCB/PHA and Emergency Planning & Business Coninuiy Sraegic Forum. Review of WHSCT ajor Inciden Plan compleed and approved by Trus Board in arch ajor Inciden Plan awareness sessions scheduled hroughou WHSCT area. Training needs analysis o be compleed o idenify raining gaps and programme implemened HIGH 16 HIGH 12 HIGH of Failure o fully comply wih Elecrical Sysems and Asbesos Regulaions Failure o fully comply wih Elecrical Sysems and Asbesos Regulaions due o insufficien resources. This may lead o improvemen/prohibiion noices, resricion/loss of service and injury/deah of saff/paien/clien or public. reamen plans in place for majoriy of high and exreme risks. Esaes policies and procedures for all appropriae areas. AE Annual Audis AE & CP Training WHSCT Esae Sraegy Esaes Compliance Team reviews compliance wih sandards/regulaions. Upgraded Asbesos anagemen Sysem o comply wih proposed new legislaion. Page 6 of 10 Idenified risk reamen plans no fully implemened due o resource issues. Sofware Daabase of all drawings wih up o dae elecrical sysems informaion. Recurring funding no sufficien o mee all compliance issues. BSO Audi of relevan conrols assurance sandards. Auhorising engineer audi repors agains HT complian Buildings, land, plan & non medical equipmen conrols assurance sandard selfassessmen. ISO9001 Truswide. RQIA audis for regisered premises. Third pary risk assessmens for some sandards. No formal sysem of esae appraisal in pla Rewire Nurses Home Source AE & CP Training Compeen Persons o be assessed and formally appoined Implemen acion from Auhorising Engineer Repor. Removal of asbesos prioriised 14/15. Develop Esae Sraegy Secure funding for rewire of Nurses Home Removal of asbesos prioriised 15/16 Rewire of Alnagelvin Tower block Wards 7 Source appropriae sofware daabase o house all drawings wih up o dae elecrical sysems informaion. Review implicaions HT06/01 Rewire of Ward 6. Asbesos survey o be carried ou in Tower Block unnel Implemen AE Audi Recommendaions from Augus 2015 Audi. Replace HV swichgear and cable Boiler house/laundry Review PPE for HV swiching Develop scheme for remoe swiching Replace Gransha HV 31/05/ /09/ /12/ /11/ /07/ /07/ /10/ /08/ /05/ /02/ /01/ /09/ /12/ /09/ /11/ /07/ /07/ /07/2016

8 Iniial Curren Targe Assurance Framework as a 07 Augus HIGH 12 HIGH 12 HIGH of ae Backlog ainenance Tile Descripion Conrols Assurance Gaps in conrols Assurance Assurance Gaps in assurance Due dae for There is a risk of deerioraion in he Trus Esae due o lack of invesmen in he mainenance of building services infrasrucure and physical environmen which could lead o loss of service and noncompliance wih regulaory and sauory sandards. Annual review of building condiion (3i) and Lack of Funding for creaion of prioriised BL lis backlog mainenan 2016/17 Backlog mainenance programme developed Esaes Sraegy 2015/ /21 Targeing of prioriy areas as funding becomes available. Coninual bidding for funding o address backlog mainenan Backlog mainenance lis annually reviewed. Auhorising Engineer audis. BSO Audi of relevan Conrols Assurance Sandards. Environmenal Cleanliness Conrols Assurance Sandard selfassessmen. Building, Land, Plan and Non- edical Equipmen Conrols Assurance Sandard selfassessmen. RQIA inspecions/audis. Environmenal Cleanliness audis. Healh & Safey audis. Back-log ainenance lis. Creae prioriised lis of BL 30/04/2015 Creae prioriised lis of BL 31/05/2016 Creae prioriised lis BL 17/18 31/05/2017 Include backlog mainenance in 30/06/2016 capial plan presened o CT Procure and carry ou schemes 30/10/2015 Presen BL paper o CT 30/04/ /05/ /04/ /06/ /09/ EXTR E 15 EXTRE 8 HIGH edical s associaed Waer Borne Pahogens As a resul of parial compliance Waer Sysems Safey Regulaion HT-04-01,HSC L8, HT 0401 PARTA,B,C 2016 here is a risk of exposure o waer borne pahogens which may resul in injury/deah o paiens/saff. Planned programme of esing and remedial mainenance as required. assessmen. WH&SCT and Inerserve Waer Safey Plans. Flushing regime for lile-used oules. Waer Safey Working Group. Implemenaion of Zeasafe waer compliance ool. Persons appoined for Waer Safey. Waer borne pahogen esing by Public Healh Laboraory. Insufficien recurring resources o provide full compliance in Augmened Care areas. Limied mainenance regimes in low risk faciliies as risk assessed wihin waer safey plan. Limied legionella esing in low risk faciliies risk assessed as such in he waer safey plan. Independen Auhorised Engineers appoined for Waer Safey. Independen Audi of Waer Safey (November 2014). RQIA Inspecions of augmened care. Updaed assessmens included in waer safey plans CT/Trus Board Waer Hygiene Policy ay 2017 Updaed Waer Safey Plans. Independen audi of Waer Safey Ocober Waer Safey Group review implemenaion of Waer Safey Plans. Upgrade work for Greenfiels RH. 01/07/2017 Upgrade reamen wing Tower 01/11/2016 Block. 01/07/2017 Up-dae WH&SCT Waer Safey 31/07/2014 Plan. 30/09/2014 Business case o suppor upgrade for Nucleus. Coninue o follow-up appoinmen of Inerserve Auhorised Engineer. Coninue o follow-up Inerserve Waer Safey Plan. 31/05/ /09/ /10/ HIGH 16 HIGH 8 HIGH of Improveme n Governan of breach of Daa Proecion Ac hrough loss of personal or sensiive daa As a resul of gaps in saff awareness and raining in daa proecion requiremens and non-adherence o reenion and disposal guidance, here is a risk ha personal or sensiive daa could be los, inappropriaely sored or accessed; records could be reained beyond heir lifecycle and lead o a breach of confidenialiy and he Daa Proecion Ac, DoH Good anagemen Good Records Guidelines and resul in poenial enforcemen acion from he Informaion Commissioners' Office alongside damage o he Trus' repuaion. Subjec Access and Daa Access agreemen procedures. Informaion Governance/Records anagemen inducion/awareness raining. Regional code of praci Informaion Governance Seering Group. Records held securely/resriced access. ICT securiy policies. Raised saff awareness via Trus Communicaions/Share o Learn. Invesigaion of incidens. Fair processing leafles/posers. Invesigaion of incidens. Daa Guardians role. Regional DHSSPS Informaion Governance Advisory Group. Elecronic ransmission proocol. 2 secondary sorage faciliies available across NS & SS Trus Proocol for Vacaing & Decommissioning of HSC Faciliies. Scoping exercise o idenify volume and locaion of secondary close records compleed in December Daa Proecion & Confidenialiy Policy. Informaion Governance SIRO and IAO Framework. Lapops encryped & use of Trus-issued Safe Sicks. Poenial ha informaion may be sored/ransferred in breach of Trus policies. Limied upake of Informaion Governance and Records anagemen raining. ICT conrols assurance sandard. BSO Audi of ICT and Informaion anagemen Sandards. Informaion anagemen Conrols Assurance Sandard. Repors o anagemen Sub- Commiee/Governance Commiee BSO Inernal Audi of Informaion Governan Revised composiion and erms of reference of he Informaion Governance Seering Group as a resul of he new SIRO/IAO framework. Begin roll ou of single e- 31/03/2018 learning module Review implicaions of GDPR 30/06/2017 for Trus in erms of reenion of 31/12/2017 records, processes and procedures, raining and awareness Complee furher scoping exercise o idenify volume and locaion of secondary closed records across Trus Review Sraegic Direcion in relaion o secondary sorage faciliies and elecronic records sorage plans (e-healh sraegy) IG Assurance Inspecion Week Page 7 of 10

9 Iniial Curren Targe Assurance Framework as a 07 Augus EXTR E 20 EXTRE 8 HIGH of Nursing, Primary Care & Older People's ae Tile Descripion Conrols Assurance Gaps in conrols Assurance Assurance Gaps in assurance Due dae for ha paiens may experience a reduced qualiy of nursing care ha paiens in acue and primary care and older people's secondary care services may experience a reduced qualiy of nursing care due o unplanned saff absence and vacan poss ha canno be filled, which resuls in a reliance on bank and agency nursing saff and he associaed financial risks. Review of nursing resources, influence Commissioner, use of emporary conracs. onioring of performance hrough KPIs. Daily monioring of saffing s and bank/agency usage. Daily senior managemen paien flow walkabous. onioring of escalaion beds. Twice daily bed managemen meeings. Abseneeism policy; E-rosering sysem. No bank only conracs in pla Clinical supervision. Normaive saffing has been compleed in COE wards. ITR's have been processed Nurse Saffing Reviews compleed in a range of Acue and PCOP wards in Alnagelvin and SWAH using he Safer Nursing Care Toolki. Reviews compleed in Alnagelvin - Ward 1, Ward 3. SWAH Wards 5,6,7. Ward 1. Where he need for addiional nursing saff required - proposal submied o responsible ae anagemen Teams. Nursing Saffing Reviews compleed in Alnagelvin Ward 44, Ward 20. onhly review of paien falls hrough Falls Acion Group. Quarerly review of nursing medical errors. onhly review of nursing complains. Ongoing saff reviews. onhly accounabiliy reviews on qualiy of paien care. Nursing Validaion. Beyond he Grapevine RQIA inspecions Absences are being managed hrough he Trus's anaging 31/08/2017 Abseneeism Policy on an ongoing basis Analysis of Nursing Saff reviews in Alnagelvin Ward 44, Ward /11/2017 CT decision o iniiae 31/12/2016 Business Coninuiy iniiaive. Sood down 2/8/17 CT made decision o submi Early Aler o DOH on need o close beds due o saffing shorages and IP&C issues. aes aken o close 25 beds in Alnagelvin Hospial due o nurse saffing shorages. Regular vacancy monioring hrough Band 5 sabilisaion monioring 103 Adul Nurse Graduaes employed. Working owards regisraion a oal of 84 RN employed hrough regular recruimen sessions 02/08/ /07/ /07/ /12/ EDIU 12 HIGH 9 EDIU of Acue Hospial odernis aion.wo rkfor o paien/clien safey because of insufficien edical cover in PCOPS and edical Wards in SWAH Insufficien medical saff a weekends in SWAH o effecively cover he number of edical & Care of Elderly wards - Older persons wards defauled o F1 grade. Referred o NTA and School Board of edicine. Raised wih Commissioner. edical prioriisaion. Consulan on-call roa in place No overnigh or weekend Nigh suppor for medical eam. Insufficien medical cover a weekends and nigh Addiional pos secured in OPAL Service in SWAH which may relieve pressure in COE wards. Awaiing funding from Commissioner o progress recruimen. Compleion of Business case for edical cover 31/07/ HIGH 9 EDIU 1 LOW of Childrens Adul Safeguarding of unallocaed cases across service Governa npubl ic Confidenc e.financi al anagem en & Referrals direcoraes in respec of adul safeguarding work due o workload pressures. Ongoing monioring of safeguarding wihin service direcoraes. New model for riage and iniial assessmen of safeguarding referrals has been implemened. Lack of resources o manage he increased workload. RQIA inspecions./reviews. onioring hrough delegaed sauory funcions by he HSCB. Execuive of Social Work review of safeguarding models of service delivery. 22/12/ EDIU 9 EDIU 6 LOW Chief Execuive Financial The Trus's abiliy anagem o achieve en & Recurren Balance ha he Trus will fail o breakeven in he curren and fuure years given he reliance on non-recurring measures and he challenge in mainaining hese in he medium o long erm wihin he conex of coninuing cash releasing savings and increasing demand. An overseeing role by he HSCB in he form of Service Reform and Financial Accounabiliy Board. Projec Srucure esablished o oversee he developmen and implemenaion of Recurren Balance Soluions. Annual Review of Recurren Balance posiion. onhly monioring of he delivery of he financial plan by CT FG and he Trus Board. The developmen of an annual financial plan. Service Reform and Financial Accounabiliy Projec Board. Inernal Audi. Implemenaion of he Recurren Balance Soluions Projec Iniiaion Documen (P) Page 8 of 10

10 Iniial Curren Targe Assurance Framework as a 07 Augus EXTR E 20 EXTRE 9 EDIU of Acue Hospial ae Acue Hospial odernis aion.pu blic Confidenc e.workfo rparn erships.f inancial anagem en & Tile Descripion Conrols Assurance Gaps in conrols Assurance Assurance Gaps in assurance Due dae for Acue shorage of There is chronic shorage of radiologiss in Breas Radiologiss WHSCT. in WHSCT 1. Poenial suspension of Breas Screening service provided by he Wesern Breas Uni resuling in loss of service o ladies in he screening group 2. Reducion in provision of breas radiologis for riple assessmen clinics resuling in risk of delayed diagnosis of breas cancer 3. Highly visible and sensiive are of work. There is likely o be a high of public and media ineres should eiher service be unavailable. Poenially very damaging o he rus s repuaion as a provider of screening and sympomaic services. The issue has been highlighed as par of he Imaging Review There are 4 screening unis in NI 2 of which have a full complemen of breas radiologiss and 1 in a similar posion o WHSCT This includes escalaion via he anaged Radiology Clinical Nework (RCN), QARC and PHA WHSC Trus has approached he oher russ in NI for occasional suppor wih very limied success The Trus is acively recruiing 2 breas radiologiss bu is unlikely o be successful in his round as here are no raining radiologiss in his specialy who have expressed an ineres in WHSCT There are plans o furher role exend he breas radiographers o include Ulrasound of he breas alhough here is a significan lead in ime Radiographers in Nuclear edicine perform seninel node injecions. 1 Role exended radiographer underakes film reading and breas biopsies wih anoher in raining. WHSCT has 2 breas radiologiss and a hird who underakes sympomaic work on an ad hoc basis since his reiremen Breas Screening arges re reporing ime and assessmen imes are a risk. Sudden surges in demand e.g. following TV campaigns can be accommodaed wihin he specified miniserial arge. Wih a wo breas radiologiss 52 week cover canno be guaraneed. Boh services have been mainained largely by huge effors by he wo remaining Full ime breas radiologiss bu here is a risk ha eiher may no be available permanenly and one is due o reire wihin he nex 2-3 years. Exernal oversigh by QARC and inspecion by RQIA has indicaed ha he services provided are safe and fi for purpose. QARC, PHA, HSCB and clinical colleagues are aware of he posiion and i has been escalaed hrough all known channels Immediae regional discussion wih HSCB or oher russ o enquire if radiology breas resources can be readily available o WHSCT QARC and RCN informed and reques made for suppor Surgical Teams informed of poenial issues 08/03/ /03/ LOW 9 EDIU 4 LOW of Childrens Delegaion of adminisraion of medicaion and specialised asks in Shor Break Residenial Faciliies. Children availing of residenial shor breaks who require adminisraion of medicaion ha canno be delegaed o he curren saffing resource wihin he uni. A nurse is required for adminisraion. Nursing saff on duy o adminiser medicaion as required. Planning ahead and ensuring relevan saff on roa o cover his ask while children are in residenial shor break. Nursing inpu will be planned when here is a delegaion issue. This acion is ongoing. 30/06/2017 Children and Young People who require adminisraion of medicaion by nursing saff o avail of services via The Coages as far as possible. Issue o be raise regionally by of Women& Children's EDIU 12 EDIU 4 LOW Chief Execuive odernisa ion.publ ic Confidenc e.financi al anagem en & Failure o comply The risk ha he Trus will breach UK wih procuremen legislaion re social care procuremen procuremen legislaion rules in awarding conracs for he provision of social care services. The legislaion oulines ha a formal ender process mus be followed when awarding conracs ha are expeced o be above a specified hreshold. This is o be managed by BSO PaLS on behalf of all Truss bu he curren proposed work programme means ha Truss will no be fully complian wih he legislaion for a period of 5 years ending on 31 arch The issue has been discussed a he Trus's Procuremen Board and Social Care Procuremen Group. The Trus's of Finance & Conracing has highlighed his issue o he Regional Procuremen Board. The Trus does no have he resource or infrasrucure required o manage his risk inernally. DHSSPS has deermined ha he issue should be managed regionally. Coninue o monior progress a Regional Procuremen Board, Trus Procuremen Board and Social Care Procuremen Group. Page 9 of 10

11 Iniial Curren Targe Assurance Framework as a 07 Augus HIGH 16 HIGH 8 EDIU of Nursing, Primary Care & Older People's ae Public Confidenc e.parne rships.fi nancial anagem en & ode rnisaion. Tile Descripion Conrols Assurance Gaps in conrols Assurance Assurance Gaps in assurance Due dae for Inabiliy o access domiciliary care in a imely manner There is a risk ha boh hospial paiens and communiy service users will no receive heir assessed domiciliary care package in a imely manner. Paiens delayed in hospial may be a greaer risk of infecion and/or falls. Paiens in he communiy may be a greaer risk of falls or oher injuries. Communiy Inerim addiional roas have been esablished in 12 locaions across he Trus hrough a coordinaed exercise o address issues where accessing service provision has been idenified across all POC s. The Trus will now award new conracs for is independen secor service provision. The service users may have o wai longer for heir process of implemenaion will be managed assessed care package as hospial paiens hrough a srucured projec managed approach may be prioriised for care packages o wih a risk regiser o ensure ransiional mainain hospial flows. Adul Communiy arrangemens are managed and risks Care Divisions are experiencing difficulies minimised. wih accessing responsive domiciliary care The Trus coninues o implemen is reablemen service provision due o he following service model which is operaionally linked o facors; he reform of is in-house homecare servi Uncerainy and ransiional processes wihin The combinaion of hese measures is will assis he independen secor linked o he re-ender in addressing he risks being experienced and of independen secor domiciliary care repored. conracs. Ruraliy and he abiliy o source and secure a susained domiciliary care service provision in some remoe areas across he Trus The curren reform of he Trus s in-house Homecare Service This risk is impacing service users and carers across boh communiy and hospial care seings resuling in delayed discharges, emporary placemens being made in nursing and residenial homes and unme need being repored which is impacing service users and heir families / carers. There is unme need due o financial consrains and difficulies associaed wih ruraliy. PCOP Domiciliary Care Waiing Lis There are a range of monioring and reporing processes in place o ensure his risk is acively moniored A service response o assessed need is progressed on each individual cases hrough keyworkers and brokerage Acions are aken wih regards o he posiion as repored hrough hese assurance and monioring mechanisms PFA Discharge Targes Daily Delayed Discharge Repor The focus remains o ensure opimum uilisaion of available resource and progress acions in areas where here are clusers of unme need Toal assurance canno be given as he demand and locaion of cases canno be projeced or planned for. Negoiae new conracs wih Independen Secor providers. ember of Reablemen seering group Discussing individual prioriy cliens wih providers o reorganise care Providing a range of alernaives, e.g. direc paymens Procuremen for dom care is almos complee 21/04/ /04/ /04/ /04/ /04/ /09/ /09/ /02/ /09/ /09/2016 Page 10 of 10