SOMERSET PARTNERSHIP NHS FOUNDATION TRUST. REPORT ON ASSURANCE FRAMEWORK AND CORPORATE RISK REGISTER Report to the Trust Board 6 February 2018

Transcription

1 F SOMERSET PARTNERSHIP NHS FOUNDATION TRUST REPORT ON ASSURANCE FRAMEWORK AND CORPORATE RISK REGISTER Report to the Trust Board 6 February 2018 Sponsoring Director: Authors: Purpose of the report: Director of Governance and Corporate Development Secretary to the Trust Head of Corporate Business/Risk and Compliance Manager The Assurance Framework sets out the risks to the Trust of achieving its strategic objectives for 2017/18 and the actions in place to mitigate those risks. The Corporate Risk Register sets out the current risks identified by the Trust through risk assessment as having a VERY HIGH impact on the delivery of its services, together with the actions in place to mitigate those risks. The Trust s risk appetite indicates that any risks rated as 15 or over on its risk matric require immediate intervention and mitigating action plans. Key Issues and Recommendations: The current highest risks to the Trust achieving its objectives for 2017/18 are identified as: the recruitment and retention of staff; the delivery of the financial targets; the impact of the development of the Somerset Sustainability and Transformation Plan; failure to effectively involve patients and carers in the development and delivery of services and care. Assurance Framework and Corporate Risk Register Progress Report February 2018 Public Board - 1 -

2 F Both in terms of the Assurance Framework and the Corporate Risk Register, staffing and recruitment remains the most significant risk and this is reflected in locally managed risks at service and team levels as well. Risks that have increased during the period relate to: failure to effectively involve patients and carers in the development and delivery of services and care; failure to implement appropriate approaches to working across health and social care within and beyond the STP proposals make the Trust and the wider health economy unsustainable and impacts adversely on patient care; recruitment and retention of nursing, medical and other professional staff; increased demand on the district nursing service; pressures on community hospitals; reputation as both Employer and Provider; loss of in-hours medical cover in a community hospital; response times for ambulance calls (new risk); patient care provision by the Overnight District Nursing Service when reduced tot wo teams (new risk); shortfall in dental capacity in the Isle of Wight (new risk). The Assurance Framework and Corporate Risk Register were presented to the January 2018 Quality and Performance Committee and January 2018 Audit Committee meetings. Assurance Framework and Corporate Risk Register Progress Report February 2018 Public Board - 2 -

3 F Actions required by the Board: The Board is requested to discuss the risks and the mitigating actions identified and approve the Assurance Framework and Corporate Risk Register. Assurance Framework and Corporate Risk Register Progress Report February 2018 Public Board - 3 -

4 F Assurance Framework and Corporate Risk Register Progress Report February 2018 Public Board - 4 -

5 F SOMERSET PARTNERSHIP NHS FOUNDATION TRUST ASSURANCE FRAMEWORK AND CORPORATE RISK REGISTER 1. PURPOSE OF THE REPORT 1.1 This report presents to the Quality and Performance Committee the Somerset Partnership NHS Foundation Trust Assurance Framework and the Corporate Risk Register for the period to 30 January ASSURANCE FRAMEWORK Background 2.1 The Assurance Framework identifies which of the Trust s strategic objectives may be at risk because of inadequacies in the operation of controls, or where the Trust has insufficient assurance. At the same time it encompasses the control of risk, provides structured assurances about where risks are being managed and ensures that objectives are being delivered. This allows the Board to determine how to make the most efficient use of resources and address the issues identified in order to improve the quality and safety of care. 2.2 The Assurance Framework is a key element of the governance documents used by the Trust to inform its declaration of compliance with the Essential Standards of Quality and Safety and the Annual Governance Statement. As part of the audit process both the external and internal auditors review the adequacy of the Assurance Framework. The Board is expected to have had a framework in place for each full year being reviewed. 2.3 At its meeting on 13 December 2016, the Trust Board agreed the following revised Strategic Objectives for the period of the two-year operational plan 2017/ /19: In partnership with our patients, carers, colleagues and partner organisations, we will: 1. deliver person-centred care in the most appropriate setting (service delivery). 2. continuously seek to improve the quality of care and support we provide (quality and safety). 3. recruit, retain and support a workforce to deliver high quality, cost effective care (culture and people). Assurance Framework and Corporate Risk Register Progress Report February 2018 Public Board - 5 -

6 F 4. work together to deliver and support sustainable services (sustainability and transformation). 5. identify, invest in and promote good practice and innovation (sustainability and transformation). 3. ASSURANCE FRAMEWORK GOVERNANCE ARRANGEMENTS 3.1 The Audit Committee is responsible for reviewing the levels and effectiveness of the assurances that the Board received in respect of the risks identified, ensuring that these are relevant and timely. 4. GAPS IN CONTROL AND ASSURANCE 4.1 The Executive Team has updated the Assurance Framework to reflect changes in the risks facing the Trust but no new risks have been added since the presentation to the Board in November The key risks to the Trust achieving its objectives for 2017/18 are identified as: the recruitment and retention of staff; the delivery of the financial targets; the failure to implement appropriate approaches to working across health and social care within and beyond the Sustainability and Transformation proposals which could make the Trust and wider health economy unsustainable and impact adversely on patient care; failure to effectively involve patients and carers in the development and delivery of services and care. 4.3 A summary of actions to address the key risks are set out in the Assurance Framework but each is supported by an action plan to address the issues raised and the response is co-ordinated by the nominated lead executive director. These details are set out in the Assurance Framework summary attached. 5. CORPORATE RISK REGISTER 5.1 It is mandatory healthcare organisations have a corporate risk register which shows all significant risks on an ongoing basis. The purpose of the Corporate Risk Register is to provide assurance the Trust has Assurance Framework and Corporate Risk Register Progress Report February 2018 Public Board - 6 -

7 F identified and is managing its most significant risks i.e. that the Trust is putting in place effective controls and managing mitigating actions and to provide an accurate statement of the Trust s risk current maturity. These risks differ from those on the Assurance Framework in that they may be short term and readily addressed or mitigated without affecting the Trust s overall ability to achieve its strategic objectives. 5.2 For Somerset Partnership NHS Foundation Trust, the risks on the Corporate Risk Register are those which have been rated as 15 or greater using the Trust s risk assessment matrix (as set out in the Trust s Risk Management Policy). The Risk Registers help to focus the need for intervention and resources for the Trust in areas that require immediate action or response. Corporate Risk register 5.3 The Corporate Risk Register is reviewed monthly by the Senior Management Team and quarterly by the Quality and Performance Committee and Trust Board. New Corporate Risks 5.4 During the period three new risk have been added to the Register: SO4 Shortfall in capacity in IOW following failure to recruit to Band A post and ongoing HR issue, impacting on Occasional Care and Minor Oral surgery risk has been rated as 3 x 5 (January 2018); MIU response times for ambulance calls increase in delays on transporting sick patients to definite care due to increasing pressure on ambulance service risk has been rated as 3 x 5 (January 2018); MIU patient care provision by the Overnight District Nursing Service when reduced to two teams risk has been rated as 3 x 5 (January 2018); Corporate Risks Removed 5.5 Two risks were transferred from the Corporate Risk Register to Local Risk Registers during this period: decontamination of sonography probes; interface of ICNET with clinical systems. Corporate Risks Reduced 5.6 The following risks were reduced during this period: Dental services in Dorset and Isle of Wight; Assurance Framework and Corporate Risk Register Progress Report February 2018 Public Board - 7 -

8 F High impact seasonal flu outbreak; Sustainability and Transformation. Increased Risks 5.7 The following risks have increased during the period: CHS1 - Recruitment and retention of nursing, medical and other professional staff in order to protect patient safety by ensuring a more robust staff team, three community hospital wards have been temporarily closed with the consolidation of beds onto ten sites (from 13) and consolidation of OPMH dementia assessment at Pyrland Ward. A revised recruitment and retention strategy has been developed as part of the alliance work plan and the action plan is being monitored; DNS07171 Increased demand on the district nursing service - a priority framework and recommendations from the Benson review have been implemented and data from this review will be reported to the DN Transformation Board and NRM meeting. EWTT data was also being closely monitored; CHS32 Pressures on community hospitals inpatient beds have been consolidated onto fewer sites to sustain staffing levels. A recruitment and retention plan had been developed. The roll out of the Home First service will continue and steps were being taken to address Delayed Discharges of Care. In addition, a new alliance project to modernise practice and system for inpatient flow and delayed discharges of care was being implemented. An additional 19 beds were opened during OPEL 4 escalation; CG/2017/11.01 Reputation as both Employer and Provider This was linked to the temporary closure of inpatient beds at Shepton Mallet, Chard and Dene Barton community hospitals. Mitigating actions included the implementation of a plan for engagement and consultation between November 2017 and January 2018; MD10 Loss of in-hours medical cover in a community hospital mitigating actions included the establishment of a working group to review the community hospital clinical model. The first meeting scheduled for 29/11/17 was postponed as further clarity around future role of community hospitals is needed. Assurance Framework and Corporate Risk Register Progress Report February 2018 Public Board - 8 -

9 F 6. CONCLUSION 6.1 The Trust maintains a good control on the most significant risks to achieving our strategic objectives. However, progress towards achievement of the reduction in risk levels, particularly in relation to recruitment and staffing, has been limited in line with pressures regionally and nationally. 6.2 Both in terms of the Assurance Framework and the Corporate Risk Register, staffing and recruitment remains the most significant risk and this is reflected in locally managed risks at service and team levels as well. 7. RECOMMENDATION 7.1 The Board is asked to discuss the Assurance Framework and Corporate Risk Register and note the actions being taken to address the risks identified. Assurance Framework and Corporate Risk Register Progress Report February 2018 Public Board - 9 -

10 F Links to Strategic Themes: Links to the Assurance Framework: Links to the Trust Values: Identify to which of the Somerset Partnership NHS Foundation Trust strategic themes this report relates by including a tick behind the relevant theme(s) Quality and Safety Service Delivery Sustainability and Transformation Culture and People Identify to which risks of the Assurance Framework this report relates the report relates to all risks on the Assurance Framework. Identify the Trust Values to which the issues raised in this report Working together Making a Difference Everyone counts Links to CQC Domains: Identify which of the CQC domains are covered by this report by including a tick behind the relevant domain(s) Is it safe? Is it caring? Is it well-led? Is it effective? Is it responsive to people s needs? Equality: The Assurance Framework and Corporate Risk Register is not equality impact assessed. Z Age Gender re-assignment Pregnancy and maternity Religion or Belief Disability Marriage and Civil Partnership Race Sex Sexual Orientation Assurance Framework and Corporate Risk Register Progress Report February 2018 Public Board Learning Disabilities

11 F Legal or statutory implications/ requirements: NHS Improvement Single Oversight Framework; NHS Improvement Code of Governance; CQC Essential Standards Public/Staff Involvement History: Previous Consideration: the Assurance Framework is developed by the Board and reviewed and updated by the Senior Management Team. The Corporate Risk Register is compiled from risk assessments and incident reporting undertaken by all staff and recorded on the DATIX system. the Assurance Framework is regularly reviewed by the Audit Committee, Quality and Performance Committee and the Board and the Corporate Risk Register is reviewed by the Board and Quality and Performance Committee. The Corporate Risk Register was also presented to the January 2018 Audit Committee meeting; the Corporate Risk Register is reviewed monthly by the Senior Management Team. Assurance Framework and Corporate Risk Register Progress Report February 2018 Public Board

12 APPENDIX 1 ASSURANCE FRAMEWORK 2017/18 Q3 SUMMARY REPORT Ref Risk 1.1 The Trust fails to make the best use of available capacity in our community hospitals and mental health inpatient wards leading to delayed transfers of care and patients being looked after in inappropriate settings 1.2 The Trust fails to meet waiting time targets for key services leading to poor patient experience and outcomes 1.3 The Trust loses access to inpatient or other facilities due to fire, flood or other disruption, resulting in loss of capacity to deliver services Board Lead(s) COO COO DSCA Relevant Action Plan(s) Operational Plan Operational Plan Business Continuity Plans Capital Plan Linked Risks MH1b CHS1 CHS33 MD10 West WH3 PCD1 EPRR1 Responsible Group(s) HSSE Q4 Q1 Q2 Current risk Target Risk Progress Last Review /12/ /12/ /12/ The Trust fails to effectively involve patients and carers in the development and DSCA PPI Action Plan Quality PCIG CGG /12/17 Assurance Framework and Corporate Risk Register Progress Report Summary Report February 2018 Public Board - 1 -

13 APPENDIX 1 delivery of personcentred services and care Account Assurance Framework and Corporate Risk Register Progress Report Summary Report February 2018 Public Board - 2 -

14 APPENDIX 1 Ref Risk 2.1 The Trust fails to meet the CQC fundamental standards of care Board Lead(s) DNPS Relevant Action Plan(s) CQC Action Plan Service Improvement Plans Linked Risks SCA1 CHS32 CHS33 MH12 MH9 MD10 Responsible Group(s) Q4 Q1 Q2 Current risk Target Risk Progress Last Review CGG /12/ The Trust fails to meet its quality targets for reducing harm and improving the quality of care 2.3 The Trust fails to effectively involve patients and carers in the development and delivery of services and care MD PB Operational Plan Quality Account Patient and Carer engagement NPS19 CGG PCI /12/ /12/ The Trust fails to take sufficient action to avoid, investigate or learn from serious incidents DNPS SIRI Policy and Action Plans Complaints Policy and Action Plans SRG CGG CGG PCIG /12/ The delivery of the financial requirements on the Trust under the MD STP Turnaround PCD1 SCA /12/17 Assurance Framework and Corporate Risk Register Progress Report Summary Report February 2018 Public Board - 3 -

15 APPENDIX 1 Somerset STP, the turnaround plan and the Trust s financial targets impact adversely on the quality of services Plan CIP Assurance Framework and Corporate Risk Register Progress Report Summary Report February 2018 Public Board - 4 -

16 APPENDIX 1 Ref Risk 3.1 The Trust fails to recruit and retain sufficient staff to maintain safe services Board Lead(s) DWOD DNPS Relevant Linked Action Plan(s) Risks OD Plan CHS 32 CHS33 CHS 34 MH1a MH1b CHS1 CYP10 MD10 MD12 West WH3 Responsible Group(s) OPG CGG Q4 Q1 Q2 Current risk Target Risk Progres s Last Review /12/17 Assurance Framework and Corporate Risk Register Progress Report Summary Report February 2018 Public Board - 5 -

17 APPENDIX 1 Ref Risk 4.1 The Trust fails to achieve its financial control total which leads to failure of the local risk share arrangements, potential regulatory intervention and impacts on the Trust's future viability STRATEGIC THEME SUSTAINABILITY AND TRANSFORMATION STRATEGIC OBJECTIVE (SO4): We will work together to deliver and support sustainable services Board Relevant Linked Responsible Current Q4 Q1 Q2 Lead(s) Action Plan(s) Risks Group(s) Risk DFBD Operational Plan PCD1 EPRR1 Target Risk Progress Last Review /12/ Failure to implement appropriate collaborative approaches to working across health and social care within and beyond the STP proposals makes the Trust and the wider health economy unsustainable and impacts adversely on patient care DFBD STP Turnaround Plan Operational Plan SCA2 IP /12/17 Assurance Framework and Corporate Risk Register Progress Report Summary Report February 2018 Public Board - 6 -

18 APPENDIX 1 STRATEGIC THEME SUSTAINABILITY AND TRANSFORMATION STRATEGIC OBJECTIVE (SO5) We will identify, invest in and promote good practice and innovation from within our Trust Ref Risk Board Relevant Linked Responsible Current Target Last Q4 Q1 Q2 Progress Lead(s) Action Plan(s) Risks Group(s) Risk Risk Review 5.1 The Trust fails to develop its information and technology systems to meet the changing DFBD IM&T Strategy and Action Plan CIGG1 CIGG2 CIGG demands of clinical and healthcare delivery which creates barriers to effective working and potential patient safety concerns /12/17 KEY Board Leads COO Chief Operating Officer DNPS Director of Nursing DWOD Director of People and Organisational Development DSCA Director of Governance and Corporate Development MD Medical Director DFBD Director of Finance Responsible Groups Senior Management Team HSSE Health, Safety, Security and Estates Group OPG Our Partnership Group CIGG Caldicott and Information Governance Group CGG Clinical Governance Group PCIG Patient and Carer Involvement Group SRG SIRI Review Group Progress risk level reduced risk level increased risk level maintained Assurance Framework and Corporate Risk Register Progress Report Summary Report February 2018 Public Board - 7 -

19 01/04/ /01/2018 Risk Exec Lead Date Raised Responsible Gov Group (CG/RG/IG/ET) Impact Likelihood Inherent Risk Impact Likelihood Current Residual Risk Direction of Travel Review Date Target Risk Score Inherent (score before any action taken) Residual (score after controls) Risk Identification Action Plan ASSURANCE Control /Assurance Gap EXISTING CONTROLS i.e. evidence relating to the specific Risk Description i.e. actions already fully implemented measures under Existing Controls. Can be positive + or negative - What additional actions need to be taken to manage this Action Plan Summary (Progress against actions planned to close to manage risk STATE WHETHER ASSURANCES ARE risk (including timescales) OR identified gaps) (+) OR (-) AND THE DATE what additional assurances REC'D/FREQUENCY do we need to seek Strategic Theme: SERVICE DELIVERY Strategic Objective 1 (SO1): We will deliver person-centred care in the most appropriate setting AH The Trust fails to make the Extensive work undertaken with Board performance reports 1. Need for STP/Commissioner 1. Bespoke project commenced within the best use of available partner agencies as part of the STP (monthly) (-) strategy review to define SomPar/T&S alliance to improve patient flow to and capacity in its community programme to deliver and sustain major Internal audit on county-wide future configuration of within community hospitals with a key objective of hospitals and mental health performance improvements in patient Delayed Transfers of Care (-) community services, reducing overall LoS by 5.4 days, equivalent to 40 inpatient wards leading to flow and reduce DToC across the Delayed Transfers of Care reviewed pathways and the role of additional beds in community hospitals. delayed transfers of care system. on a bi-monthly basis by the Quality community hospitals. and patients being looked Weekly system wide performance and Performance Committee 2. Severe and persistent 2. Extensive work undertaken continues with partner after in inappropriate metrics now in place and overviewed on During periods of heightened shortages of registered agencies as part of the STP programme to deliver settings a multi-agency basis by the bi-weekly escalation, performance (via bed nurses continue to threathen and sustain major performance improvements in DToC Group. availability) reported on a twice daily ability to maximise use of patient flow and reduce DToC across the system. Monthly reporting within the basis via system strategic calls capacity within the Trust and operational finance and performance Effective use of inpatient capacity efforts to improve patient 3. New focus on Home First and building of capacity meeing and also at the Senior has resulted in reduction in acute flow. for these services represents core and future 8 Management Team meeting. hospital DToCs in the region of 40- strategy to maintain patient flow in community Bespoke project commenced within 50% (+) services. the SomPar/T&S alliance to improve system wide DToC performance patient flow to and within community reviewed on a fortnightly basis by the hospitals with a key objective of system wide DToC Group and overall reducing overall LOS by 5.4 days, now showing a reduction of 60-70% equivalent to 40 additional beds in non 2016 levels. community hospitals. New mental health inpatient admission protocol adopted with key roles identified within the directorate team. part of strengthening the bed management function within the Home Treatment Service.

20 01/04/2016 HSSE 08/01/ /04/ /01/2018 AH The Trust fails to meet waiting time targets for key services leading to poor patient experience and outcomes Comprehensive performance management arrangements, to track progress against key waiting time targets Standing agenda item at key internal forums including the Operational Directorate Finance and Performance meeting Monthly reporting to Senior Management Group Quarterly contract review meetings with CCG Action plan implemented for psychological therapies/iapt services Action plan in place for dental services and disucssion underwaty with service commissioners on contract structure. Board Performance Reports (monthly) (+) Quality and Performance Committee reports and minutes (bi-monthly) (+) Friends and Family Test results (monthly)(-) Complaints and PALS reports (quarterly) (+) CQC Provider report and core services reports (-) Monthly operational finance and performance meetings Monthly senior management team meetings Ensure trajectories are met within dental servics for units of dental activity 2. Severe and persistent shortages of key registered staff continue to impact on capacity and service delivery within the Trust 3. Increasing demand across a range of services, particularly notable in child and adolescent mental health services 1. The number of people waiting over 18 weeks as at 30 November 2017 was 149, a reduction of 36 patients compared to 31 October 2017, and a reduction of 60 patients compared to 31 March The service with the largest number of people waiting over 18 week remains our dental service. The recruitment of more dentists has helped reduce the numbers waiting, from 174 as at 31 March 2017 to 95 as at 30 November The service with the next highest number of people waiting over 18 weeks is our Integrated Therapy Service for Children and Young People, with 37 children and young people waiting over 18 weeks. We are currently undertaking capacity modelling work in order to inform our approach to reducing waiting times for this service. 8 PB The Trust loses access to inpatient or other facilities due to fire, flood or other disruption, resulting in loss of capacity to deliver services Estates strategy Evacuation and Shelter policy procedures and local plans Lockdown policy, procedures and local plans Business Continuity Policy and plans Exercise testing of plans Fire Risk Assessments Estates maintenance programmes Incident Response plan Reports to Estates and Facilities Group Reports to Health, Safety, Security Management and Estates (HSSE) Group Memorandum of Mutual Aid with other organisations Incident response training LHRP assessment by NHS England (annual) (+) Exercise testing results and briefings (+) Annual Fire Safety submission (annual) (+) Reports of HSSE to Quality and Performance Committee (six monthly (+) EPRR Assurance review moderated by NHS England and Somerset CCG (annual) (+) Need to exercise all Business Continuity Plans across all sites 2. Need to ensure the impact of increased cyber-security threat is managed to protect business continuity 1. Exercise programme established and table top exercises being undertaken on rolling programme. All mental health inpatient wards and community hospitals have completed exercises (Jun 2017) No sites in Somerset have been identified as high risk in respect of the issues affecting Grenfell Tower. Monthly fire safety meeting eslatblished to review position. 2. Increased capacity established within the IM&T team to provide focus on cyber security. Disaster recovery plans and business continuity within IT services under review. 5

21 01/04/ /01/ /04/2015 PCIG 08/01/2018 PB The Trust fails to effectively involve patients and carers in the development and delivery of services and care Quality Improvement Plan and implementation plan Triangle of Care Steering Group Voluntary Sector Forum League of Friends Forum Communications and PPI Strategy and Action Plans PPI Best Practice Group Monitoring through PPI Group Friends and Family test results Complaints and PALS investigations Quality Account priorities Patient Surveys PPI Workbooks STP Engagement Plan and Charter Volunteer Policy and contracted service PPI Workplan Quality Report (monthly) (+) Quality and Performance Committee reports and minutes (quarterly) (+) Complaints and PALS reports (monthly) (+) Patient Experience Reports to Council of Governors (quarterly) (+) Quality Contract Review meetings with CCG (quarterly) (+) Quality Account feedback (annual) (+) Patient stories (monthly) (+) Health watch Somerset reports (quarterly) (+) Patient surveys (annual) (+) Internal Audit PPI (Nov 2014) (+) CQC Inspection report (Sept 2015) (+) Internal Audit - Volunteers (Mar 2016) (-) CQC Inspection Report (Jun 2017) Need to invest in support for patient and service user involvement within operational services 1 PPI Manager and PPI Officer in post from June Recruitment planned for mental health service user lead. 2. Consultation undertaken on Milverton Branch Surgery. 3. Proposals for consultation on Mental Health services developed and with CCG and NHS England for consideration but not currently proceeding. 4. Significant negative feedback on lack of consultation before temporary closure was enacted. Potential legal action indicated by campaign group in Shepton Mallet. Decision to be reviewed taking account of patient and public feedback (February 2018). Public workshop events held in Chard and Shepton Mallet. Consultation launched to inform February 2018 review. Consutlation will run until 22 January Strategic Theme: QUALITY AND SAFETY Strategic Objective 2 (SO2): We will continuously seek to improve the quality of care we provide HP The Trust fails to meet the CQC fundamental standards of care CQC Intelligent Monitoring CQC self assessment programme Monitoring through Executive Team Monitoring through Senior Managers' Group Service and Team Manager Away Days and Workshops Fit and Proper Persons' Test CQC Self assessment and peer review programme DN Improvement Group CQC Liaison Meetings implementation of Childen Looked After and Safeguarding action plans Children and Young People's Plan Community Hospital Transformation Board Devolved clinical governance units Quality Account priorities Quality Report (monthly) (+) CQC Inspection - Children Looked After and Safeguarding (-) CQC Provider report (-) CQC Action Plan progress reports (bi-monthly) (+) CQC Intelligent Monitoring Report (Apr 2016) (+) CQC Unannounced Visit report - CTALD (Jul 2016) (+) CQC Action Plan Internal Audit (Jan 2017) (+) Clinical Audit Programme (+) CQC Inspection report 2017 (+) CQC Action Plan 2017 progress reports (+) Need to implement action plans in response to 2017 CQC re-inspection 2. Need to put in place CQC registration arrangements for new services in: (a) Lister House (b) Shepton Mallet Health Campus 1. (a) Community Transformation Board set up in June (b) CQC Action plan developed to meet "must dos" (c) Monitoring of compliance with "must do" actions devolved to Service Directors and reporting included within governance unit reporting to clinical governance. (d) should do actions cascaded to all teams for inclusion with Quality Improvement Plan. To be reported via Service Directors through clinical governance units. (e) CQC relationship meetings to be refreshed. 2. (a) new partners being registered and applications for changes to be made (Feb 2017) Registration of partners completed and governance arrangements shared with CQC (b) Care UK to be registered as lead provider subject to finalisation of the contract (Mar 2017). Contract signed April Care UK to pursue registration following completion of sub-contracts (Apr 17) 10

22 01/01/2017 SRG/CGG 08/01/ /01/2017 CGG 08/01/2018 SO The Trust fails to meet its quality targets for reducing harm and improving the quality of care Clinical Governance reports High Risk Area reviews Monitoring through Executive Team Monitoring through Senior ManagementTeam Service and Team Manager Away Days and Workshops Quality Account priorities Quarterly Clinical Quaility Review meetings with CCG Divisional 'deep dives' to Clinical Governance Groups Early Warning Trigger Tool Patient Safety Walkrounds Patient Safety Thermometer Service Improvement Plans Clinical Audit programme 2017/18 Quality Account priorities Quality Reports (monthly) (+). Patient Safety Walkrounds (annual) (+) Monthly Early Warning Trigger Tool report (-) CQC Provider report (-) CQC Intelligent Monitoring (+) Clinical Audit Annual Report (+) Quality Account (annual) (+) Quarterly Clinical Quality Review meetings with CCG Monitor performance against the 2017/18 Quality Account priorities 1. To monitor performance against the Quality Accounts priorities through the Clinical Governance 2. To implement the QI methodology following the Board tranining session held on 27 June SB The Trust fails to take sufficient action to avoid, investigate and learn from serious incidents Clinical Governance reports SIRI reports Homicide nvestigations CQC Liaison SIRI Policy and procedure Complaints Policy and procedure Service and Team Manager Away Days and Workshops Mortality Reviews SIRI Review Group reports Medicines Oversight Group reports Complaints reports 72 hour reviews and Duty of Candour NRLS reporting Revised policy and procedure Revised SIRI Policy Non Executive Lead for patient safety Quality and Performance Report (monthly) (+) CQC Provider report (-) CQC Intelligent Monitoring escalated risk (-) Independent Homicide Investigation reports (+) SIRI and Unexpected Deaths report (monthly) (-) Quarterly Clinical Quaility Review meetings with CCG Patient Experience Reports (quarterly) (+) Board report and focused review at Quality and Performance Committee (March/April) (+) SIRI internal audit (-) Develop revised SIRI processes in line with CQC recommendations and best practice, ensuring patients, families and carers are effectively invovled 1. Board report received. 2. Internal audit completed and SIRI improvement plan monitored by Quality and Performance Committee. 3. Root Caue Abalysis Training rpogramme commenced for SIRI Investigator leads. 4. New Head of Clinical Governance and Clinical Risk started. 8

23 01/06/2015 OPG 08/01/ /01/ /01/2018 SO The delivery of the financial requirements on the Trust in delivering its responsibilities under the Somerset STP, the turnaround plan and the Trust s financial targets impact adversely on the quality of services Quality and Performance reports Operational Performance reports Patient Experience reports Complaints reports CIP Approval matrix Quality and Performance Report (monthly) (+) CQC Provider report (-) CQC Intelligent Monitoring escalated risk (-) Quarterly Clinical Quaility Review meetings with CCG Patient Experience Reports (quarterly) (+) Need to review CIP review matrix to assess impact of cost improvement savings plans 1. Revised matrix being developed to assess new and existing initiatives (Mar 2017). 2. The Medical Director and Director of Nursing are working with the Heads of Divisions to review all CIP proposals for safety and patient impact. Further reviews will take place post-implementation to monitor for unexpected impact on quality of services. (Apr 17) A revised matrix has been developed and the Medical Director and Director of Nursing continue to work with the Service Directors to review the impact of the CIPs. Strategic Theme: CULTURE AND PEOPLE Strategic Objective 3 (SO3): We will recruit, retain and support an empowered workforce to deliver high quality, cost effective care IC The Trust fails to recruit, Board approved recruitment plan Six Monthly Safer Staffing reports (- retain, support and develop Weekly vacancy report sufficient staff to maintain Fortnightly recruitment meeting safe services Datix reporting Monthly Managing the Nurse Resource Meeting Daily conference calls/ reviews with every ward E roster in place across all wards Incentives schemes Strengthened nurse bank Preceptorship programme Return to Practice programme Releasing Time to care programme 4 5 International recruitment campaigns 20 Weekly reporting of agency spend appointment of specialist recruitment leads for nurses and medical staff ). Monthly information published on website and through Unify (+). Quarterly Workforce reports (-) Monthly Early Warning Trigger Tool report (-) Quality Report (monthly) (+) CQC Provider report (-) CQC Intelligent Monitoring escalated risk (-) Temporary closure of 3 community hospitals (-) Develop Workforce Planning and Resourcing Strategy 2. Development of an Alliance Workforce and Organisational Development Strategy for Review of exixsting resoursing strategies and workforce planning activity at operational/ directorate level to inform development of workforce planning and resourcing strategy. This work to be informed by the development of Medical and Nurse/AHP Staffing Strategies and co-ordinated with Taunton and Somerset NHS FT. Dedicated resource released from integated HR Team to support workforce planning activity as part of STP development. Independent review commissioned of existing recuitment and selection process with a view to streamlining time to hire to upper quartile benchmarks - complete. Workforce planning being taken forward as part of STP development Implementation of TRAC (automated recruitment system) planned for May Suite of Somerset and Trust specific promotional material developed in use in recruitment campaigns. Revised Advert/JD/person specification documentation developed and programme of training/coaching being delivered to recruiting managers. overseas recruitment and participation in national nurse practitoner pilot scheme 12

24 01/05/ /01/ /04/ /01/2018 Strategic Theme: SUSTAINABILITY AND TRANSFORMATION Strategic Objective 4 (SO4): We will work together to deliver and support sustainable services PM The Trust fails to achieve its financial control total which leads to failure of the local risk share arrangements, potential regulatory intervention and impacts on the Trust's future viability Monitoring through Board and Reports to and minutes of Board Executive Team monthly)(+) Regular review through Finance and Finance and Investment Committee Investment Committee meetings (quarterly) (+) Annual Plan and Budgets Budgets and cost improvement plan Budget Review report signed off by the Board (Mar 2016) (+) Monthly monitoring through NHS Improvement Segmentation operational F&P (Nov 2016) (+) Monthly reports to Senior Management Review of achievement of CIPs for Group 2015/16 and outline CIP for 2016/17 (- Operational Plan 2017/ /19 ) Risk Share Agreement Cost Improvement Programme STP Need to ensure the budget holders spend within their delegated budgets 2. Regular monitoring of other CIP areas to ensure savings are delivered 3. Need to develop plans to deliver additional control total CIP 1. On target for Month 4 excluding any impact of the risk share agreement 2. CIP monitoring undertaken and reported but full CIP not being achieved and gap in recurrent savings. Shortfalls are being offset by savings in other areas 8 DS Failure to implement appropriate collaborative approaches to working across health and social care within and beyond the STP proposals make the Trust and the wider health economy unsustainable and impacts adversely on patient care Ongoing work with Health and Social Care Leadership Group Weekly updates to ET Contracts with CCG and other commissioners for 2016/17 and 2017/18 in place Annual Plan approved by the Board Senior management level involvement in STP workstreams Lister House Partnership established Joint Venture in place with Care UK STP Risk Share Agreement MoU with TST in place Joint Executive Team established Alliance Development Committee established with SCC and GP representation Contracts with CCG, SCC and other commissioners for 2016/17 (+) NHS Improvement monitoring reports (quarterly) (+) STP Updates (monthly) (+) Risk Share Agreement report (Dec 2016) (+) NHS England Stocktakes (Sept/Nov 2017) (-) Finance reports (monthly) (-) Need to implement effective plans to minimise system deficit for 2017/18 and maximise system position (Mar 2018) 2. Need to develop and contribute to effective STP and all its workstreams, including primary care, community services and acute care 1. Workstreams progressing and potential schemes (e.g. psychiatric liaison) developed for funding approval. Porgress remains slower than required for delivery of 2017/18 trajectory. Recovery plans submitted to NHS England/NHS Improvement and options for minimising system deficit considered by Trust Boards. 2. STP workstreams 'paused' pending the forthcoming clinical services review being undertaken by the CCG 10 Strategic Theme: SUSTAINABILITY AND TRANSFORMATION Strategic Objective 5 (SO5): We will identify, invest in and promote good practice and innovation from within our Trust

25 01/04/2014 CIGG 08/01/2018 DS The Trust fails to develop its information and technology systems to meet the changing demands of clinical and healthcare delivery which creates barriers to effective working and potential patient safety concerns IM&T policies and procedures. Quarterly CIGG reports and minutes. IT capital programme. Monthly ICT business meetings. Monthly IMT Operational Group reports and minutes. Annual Information Governance Toolkit submission. DATIX incident reports. Information Sharing Protocols RiO rolled out into all community hospitals. CIGG reports to Finance and Investment Committee and annual IM&T report to the Board (+) Annual Information Governance report.(+) Internal Audit (Apr 2015) (-) IM&T report to the Board (July 2016) (+) Digital Maturity Report to Quality and Performance Committee (Nov 17) (+) Need to implement year 3 of the IM&T Strategy and reflect changing working practices and impact of increased multi-agency working 1. Most actions within the IM&T strategy completed during 2016/ RiO contract extended for further 2 years as per Board decision (Apr 17) 3. Impact of sgnificantly increased cyber security threat assessed in terms of delivery of IM&T strategy and resources within the IM&T team have been reprioritised. 4. Approval of in-house solution and purchase of software licensing. Increase in IM&T budget of 1.2 million to accommodate purchase of licensing. 8 (January no further updates)

26 MIU SAFE TBC May-16 Jan-18 CYP 10 SAFE/WELL LED SO3 Dec-14 Jan-15 CHS1 SAFE/WELL LED SO3 Nov-15 Nov-15 CHS33 SAFE/WELL LED SO1 SO3 Dec-12 Jun-14 Risk ID CQC Domain BAF Strategic Objective Date Risk Assessed Date Entered to CRR Risk Monitoring Group Consequence (current) Likelihood (current) Rating (current) D.o.T =Worsened = Improved Consequence (Target) Likelihood (Target) Target Risk (Risk Appetite) Coporate Risk Register Description of Risk Current Assessment of the Risk Reducing the Risk (Actions) What is the RISK? Lead Manager(s) Lead Director(s) How do we currently CONTROL the risk? What further ACTIONS can we take to reduce the Risk What PROGRESS have we made with the planned actions Pressures in Community Hospitals National and local recruitment market for nurses gives rise to risk of failing to meet safer staffing levels Additionally, increased complexity of patients transferring from acute hospitals. Severe staffing shortages gave rise to serious concerns for continuous staffing of hospitals and therefore patient safety due to a deteriorating position on registered nurses during summer and auttumn Tracy Evans Andy Heron CGG Board approved recruitment plan July 2015 Weekly vacancy report Fortnightly recruitment meeting Monthly board report Datix reporting Monthly Managing the Nurse Resource Meeting Daily conference calls/ reviews with every ward E roster in place across all wards Review of 12 hour shifts Incentives schemes Strengthened nurse bank Contracts with nursing agencies reviewed Preceptorship programme Return to Practice programme Close partnership working with CCG to monitor deteriorating position and associated risk to patients.. Risk management plan instigated through temporary closure of beds at Dene Barton, Chard and Shepton Mallett and consolidation of staff into larger, more robust teams Consolidate inpatient beds on fewer sites to sustain staffing levels and number of beds effected Sept/Oct 2017) 2. Implement recruitment and retention plan, including commissioning overseas recruitment agency and commence recruitment (Mar 2018) 3. Continue roll out of Home First and steps to address Delayed Transfers of Care (Dec 2017). 4. Commence new alliance project to modernise practice and system for inpatient flow and delayed transfers of care Deteriotating staffing positon and reduced access to agency has required the temporary closure of inpatient wards. Mitigating actions observed to have had a postive effect, especially at South Petherton Hospital where vacancies have reduced from 50+% to almost fully staffed. Fuller staffing being observed on other wards. Staffing continues to be a challenge, as at Nov 2017, at Burnham, Williton and Minehead Hospitals. Additional 19 beds opened during OPEL 4 Escalation. Recruitment and retention of nursing, medical and other professional staff National shortage of staff nurses, currently impacting on the wards, together with various vacancies and sickness which places pressures on remaining staff to delivery care across mental health and community health services, in particular: ENPs Paediatric therapists RMNs and RGNs physiotherapists doctors school nurses Heads of Division Andy Heron SMM Close working with HR recruitment team. Close working with agencies to use regularly identified staff to ensure consistency and familiarity Board approved recruitment plan July 2015 Weekly vacancy report Fortnightly recruitment meeting Monthly board report Datix reporting Monthly Managing the Nurse Resource Meeting Daily conference calls/ reviews with every ward E roster in place across all wards Review of 12 hour shifts Incentive schemes Strengthened nurse bank Contracts with nursing agencies reviewed Joint Somerset apporach to overseas recruitment (Phillipines). Work has started on new Workforce Strategy lead by the Director of HR For regular liaison with HR regarding recruitment of staff nurses 2. To closely monitor staffing levels and report these at Board level 3. Detailed work will need to be undertaken on the retention of staff and ensuring the Trust was a good environment to work in. 4. Revised recruitment and retention strategy being developed as part of alliance work plan January 2018 In order to protect patient safety by ensuring a more robust staff team, there has been the temporary closure of three community hospital wards with the consolidation of beds onto 10 sites (from 13) and consolidation of OPMH dementia assessment at Pyrland Ward. Recruitment Strategy is in place and Action Plan is being monitored. Emerging issue with school nursing. CAMHS pressures and vacant posts Difficulty in recruiting to vacant posts at Wessex house has meant the CAMHS WEST community Consultant being seconded to Wessex house in the meantime. Outreach Team has no permanent consultant due to the two part-time consultants who previously covered this role being asked to cover the full time Community psychiatry roles in their area Claudine Brown & Ethna Bashford Sarah Oke/ Lucy Knight CGG Consideration being given to recruiting part time to widen applicant pool Head of CAMHS and Service Director in discussion with Medical Directorate team regarding ways forward Locums covering both vacant posts 2. New CAMHS Review Group established in November 2017 to review apporach to pathway and workflow management The target risk rating continues at a reducecd level. Locums covering both vacant posts Consideration being given to recruiting part time to widen applicant pool Head of CAMHS and Service Director in discussion with Medical Directorate team regarding ways forward Pressure on staffing of On Call rota with very low numbers of consultants in post The situation remains unchanged transfer delays continue reflects service pressures both locally and nationally. Encourage DATIX reporting as we do not the situation to become normal. Response times for ambulance calls Increase in delays on transporting sick patients to definitive care due to increasing pressures on ambulance service. Tracy Evans Andy Heron CGG Continue to give supportive care when delayed transfer of patients Whilst waiting for arrival constantly review situation with SWAST Complete Datix for all delayed patients Raise issues via executive team with SWAST Continue to give supportive care to delayed transfer patient s 2. Whilst waiting for arrival constantly review situation with SWAST 3. Complete DATIX for all delayed patient s 4. Raise issues via executive team with SWAST CRR - Ops High Risks

27 CYPF0617DW01 SAFE SO4 Aug-15 Sep-14 MIU SAFE TBC Dec-18 Jan-18 DNS07171 SAFE/WELL LED SO2 Jul-17 Nov-17 EPRR 2017/11 SAFE/WELL LED Coporate Risk Register High Impact Seasonal Flu Outbreak Potential for a high impact seasonal flu season during the winter of which could have significant effects on the Trust, its staff and patients and ability to continue to deliver services Andrew Sinclair Andy Heron CGG Close monitoring of influenza cases in the Trust and Somerset; Existing pandemic contingency plan which can be adapted for a high impact seasonal flu; Inpatient services have tested BCM plans in place; Ongoing vaccination of staff incentivised by contribuitions to Unicef to buy Polio vaccinations; Isolation, Outbreak, Surveillance and Infection Control policies in place; Exploring of eligible inpatients by the Trust; IPC Team monitoring cases and able to provide FFP3 training if required; National guidance on antivirals can be implemented when required; Weekly teleconferences on seasonal flu taking place; Close liaison with acute hospitals in Somerset regularly taking place with a shared webpage in place. Viral swabs in place in community hospitals Use relevant sections of the Trust s existing pandemic contingency plan to inform its response to a seasonal flu outbreak. 2. Inpatient services to review their existing BCM plans to ensure they are sufficiently robust in terms of seasonal flu. 3. Gain agreement by the Trust to vaccinate inpatients where required. 4. Consider providing viral swabs to mental health inpatient services. 5. Continue promotion of staff vaccination programme, targeting low uptake services. 6. Consideration of widening FFP3 training 7. Develop enhanced sickness management processes in case needed when sickness absence rises. Review situation in March Current flu cases remain ejanuary 2018ning vigilant in case this situation chnages. Increased demand on the DN service - capacity which has implications for staff, patients and the Trust Mary Martin Dawn Dawson CGG Daily monitoring of staffing levels Redeployment of staff between teams / share workloads Sickness absence monitoring Bank staff and overtime with appropriate permissions Manage regular breaks for staff Recording of overtime and TOIL on eroster Prioritising of patients Discharge and admission criteria to DNS Priority Framework DAILY: for local monitoring and escalating of risk. This goes onto Datix when level 2 reached. Reported at Nurse Resource Management (NRM) meeting. EWTT MONTHLY: for monitoring the DN federation s ability to perform. Reported at DNBPG monthly and NRM meeting. Benson Strategic model to look at how DNS is managing demand and forecasting any planned changes to demand or resource. Reported at the DN transformation board and NRM meeting. DN Quality Performance measures such as Trust cancelled appointments despite capacity issues DNS is a quality service. All the above information can be triangulated to provide good evidence of how the DNS is working Priority framework developed but still to be formally adopted EWTT in place Daily safer staffing model for community nursing teams still not available Demand for services has escalated Patient Care Provision by the Overnight District Nursing (DN) Service when reduced to two teams When the overnight DN service is reduced to two teams then all aspects of DN care are being compromised with potential to cause harm to patients and put staff at risk due to a 50% increase of the geographical area being managed by remaining staff. Tracy Evans Andy Heron CGG Night HCA usually drives leaving the RN free to manage incoming/ outgoing calls to patients, carers and colleagues. HCA may wish to share driving if up to 250 miles per shift. RN maintains conversations with patients and carers and provides updates re: ETA, reasons for any delays. Staff are able to meet Trust waiting times with 3 teams in operation. Less likely to achieve with just two teams operating. Delays to agreed waiting times are an unavoidable consequence of having 2 teams due to extra mileage and travelling times between patients. Trust can expect increase in complaints from dissatisfied patients/ carers and increase in Datix from staff unable to achieve care levels as they would wish. RNs communicate effectively with patients / carers and help keep stress/ anxiety levels down. The 3 teams keep in close contact and staff are aware of where their colleagues should be. More difficult to achieve if 2 teams seeing more patients and driving longer distances. Staff are able to manage this increased workload on an occasional basis (eg. To cover unexpected sickness absence) however this is difficult to manage over the longerterm On-call managers to be made aware of all considerations when asking for waking nights DN staff to move to provide Community Hospital cover so reducing the OOHs DNs down to two teams. 2. Team administrator submits a weekly Datix incident report to record those shifts that are unfilled, resulting in fewer staff being on-duty at night. RNs to submit Datix for shifts they are asked to cover in Community Hospitals at night Staffing has reduced to two teams on occasions. This is to staff sickness absence and inability to provide cover over the holiday period. New Team manager appointed and plans in place to introduce some new staff to the Waking Night Team service. Dental Services in Dorset and Isle of Wight January 2018 The position in Dorset is improving. The projected deficit by year end is now within 8% of target for Special Care and ahead of target for Occasional Care. The Isle of Wight (IOW) projected deficit is increasing due to new staffing risks on the IOW. Hence the target Risk Rating has reduced from 12 to a more optimistic 4. Capacity significant waiting list for children awaiting assessment and treatment. Financial cost of service greater than planned rental, transport, staffing Restricted access to theatre space limits ability to deliver contracted activity Governance risk associated with operating a service at a distance Small team on IOW and recent sickness has impacted on service delivery. Ethna Bashford and Debbie Hartstone Andy Heron CGG Children in pain to be prioritised and seen within 24 hours Images burnt onto CDs to view. IT solution to be identified and implemented Regular meetings held with senior dental practitoners, cochaired by FD and COO, to review operational arrangements and financial trajectory Meet activity targets to ensure appropriate level of service delivery and avoid financial penalties 2. Share information on variation in UDAs with dental practitioners. 3. Use benefits assocated with alliance arrangements to improve governance arrangements. 4. Greater use of client and professional information. March 2018: Expected to review improvement CRR - Ops High Risks