: Geraint Davies, Director of Commercial Services

Transcription

1 Report to : Trust Board of Directors Date of Report: 15/05/2015 Agenda Item: 0/15 Date of Meeting : 28 May 2015 Subject Report from Purpose : Report on Corporate Risk Register : Geraint Davies, Director of Commercial Services : For Discussion Summary : The attached paper provides the Board with an overview of Trust s recognised and recorded risks. Risks have been reviewed and updated since the previous meeting and new risks and revised ratings are outlined in the attached report. The Directorate titles at this time reflect the previous organisational structure however work is ongoing to update Directors and Directorate titles. Risk and Assurance Financial Implication Equality Impact Review : Risks presented within the Corporate Risk Register are managed and mitigated by the identified Lead Managers, with the overall responsibility falling to the Executive Lead. The status of the risks are monitored and reported every two months to the Risk Management & Clinical Governance Committee for review and discussion. : This paper has no cost implications to the Trust. Any financial implications are dealt with separately by the person(s) responsible for mitigating each risk in accordance with the Trust s financial procedures. : Has the document undergone EIA screening? No Not applicable. Date issued : 15/05/2015 Does the EIA screening mitigate the need for a full EIA? Not applicable. If No, has a full EIA been undertaken? Not applicable. Review by : Director of Commercial Services; Geraint Davies Originator : Head of Compliance; Bill Chilcott

2 Change to rating since last report South East Coast Ambulance Service NHS Foundation Trust 1 Executive Summary Trust Board Report Corporate Risk Register The Corporate Risk Register documents risks that have been graded with a risk rating of between 8 and 15. High corporate risks are considered to be those that have a risk rating of between 16 and 25. All action points addressing risk items are being overseen / implemented by the appropriate Lead Manager(s) and Accountable Executive. There are no common features in the Register which indicate a need for additional training or guidance. Overview of Corporate Risk Register 4 High Corporate Risks (rated 16 25) 42 Medium Corporate Risks (rated 8-15). 22 Continual Risks 4 New Corporate Risk (rated 8 25) 0 New Directorate Risks (rated 1 6) Risk moved from Corporate to Directorate register Risks were moved from Directorate to Corporate register 2 Existing and new High Corporate Risks (rated 16 25) Trend Rating Key // has increased // has remained the same // has decreased Title 242 Red call partition process - Risk Area: Clinical Operations 222 Paramedic Recruitment and Retention - Risk Area: Clinical Operations 147 Turnaround Delays at hospitals within the SECAmb area - Risk Area: Clinical Operations NEW Trust Board: Corporate Risk Register Page 2 of 10 Report date: 15/05/2015

3 27 Failure of the KMSS NHS 111 service to deliver financial return - Risk Area: NHS 111 & Urgent Care Risk 242 Red call partition process: There is a risk of harm to patients if the red process is not managed and monitored effectively enabling safeguards to be implemented to "Assure" that it is a safe process. If there is patient harm, which could have been prevented, there is a risk of loss of confidence in the service leading to reputational damage. (Reviewed by the Risk Equalisation Group on 5th May 2015) Actions points addressing the risk; 1. Scrutiny meetings held with the lead CCGs 2. An investigation is currently in progress examining why the system was introduced, the controls and the impact on patients, interim report by 22nd April, final report 11th May. Interim update meetings with lead CCGs until report is submitted Risk 222 Paramedic Recruitment and Retention: Unable to recruit and convert the number of paramedics to fill vacancies especially in Kent. This is resulting in an increase in the UHU and increased dependency on the use of Private Ambulance Services. (Reviewed by the Risk Equalisation Group on 5th May 2015) Actions points addressing the risk; 1. Work is continuing with developing the relationship with universities in the south east of Australia with a view to recruiting from the new graduates in the first half of It is expected that c0 paramedics will be joining the Trust in the first half of The start date is yet to be confirmed and is dependent on the different graduation dates from the Australian universities and the HCPC registration timeline. 2. Pilot for Kent re 56 ECSWs to undertake a two week course to enable them to work to a Technician Scope of Practice with effect from rd November Two NHS Trusts are now offering "golden hello" which may impact on SECAmb's ability to recruit staff going forward. Risk Turnaround Delays at hospitals within the SECAmb area: As part of the See Treat & Convey activity, the Trust relies on the ability of acute providers to receive patients, and the handover of patients and subsequent turnaround of ambulance crews are crucial to business delivery. Delays caused during this process risk causing a negative impact on patient care, as well as having a potentially detrimental effect on achievement of performance targets. The impact of such delays causes unnecessary unavailability of ambulance crews, which reduces the number of available resources. SECAmb CEO and Senior Management involvement on a regular basis which is an additional resource demand. (Reviewed by the Risk Equalisation Group on 5th May 2015) Actions points addressing the risk; 1. Ongoing monitoring of metrics for total time spent at hospital. 2. Regular reports on progress including clarity of targets and performance.. No diverts agreed. 4. No cohorting or HALOs now in place Trust Board: Corporate Risk Register Page of 10 Report date: 15/05/2015

4 Risk 27 Failure of the KMSS NHS 111 service to deliver financial return: The operational and clinical demands on providing the NHS 111 service to SLA standards has demonstrated that the resources to provide the service are greater than originally planned. This has led to an increase in core staffing and expenditure resulting in the Trust being unable to operate within the anticipated budget and diminishing the likelihood of a financial return on the service investment. (Reviewed by the Risk Equalisation Group on 5th May 2015) Actions points addressing the risk; 1. Review of staff rotas in Q4 for the Ashford Call centre to optimise efficiency. 2. Service Improvement Plan to be created (Q4) and implemented (Q1) for new financial year. New Medium Corporate Risks (rated 8-16) Title Accountable Executive: Director of Commercial Services Lack of Clinical 24 Assessment to Datix Incident Reports As part of the deep dive into incidents relating to the Red call partition process, the CCG examined 899 incidents on Datix, they concluded that they were concerned that patient safety incidents may be inaccurately recorded due to the lack of Clinical assessment at the administration phase. They conclude that if the incidents are incorrectly recorded this will lead to flawed trend analysis leading to inaccurate reporting to national systems (NRLS), to internal governance groups of the Trust and to the Commissioners, therefore they cannot be assured that patient safety is being investigated and monitored appropriately. (Reviewed by the Risk Equalisation Group on 5th May 2015) Trust Board: Corporate Risk Register Page 4 of 10 Report date: 15/05/2015

5 Title Accountable Executive: Director of Finance Defibs unable to be 244 recorded on CAD in real time Historically SECAmb have had a process to ensure all defibs/pad sites within 200m of a Cat A patient were highlighted at the time of taking the call so arrangements could be made to ensure the defib was available to be able to be taken to the patient if required. An Operational Instruction was issued (Op Instruction 111) regarding this. However unfortunately due to an error in the CAD this process has had to be temporarily suspended. This is an IT issue within the CAD and IT are aware; we are still awaiting a fix. The AQI Guidance states that defibs should be added at the time of the call. (Reviewed by the Risk Equalisation Group on 5th May 2015) Title Accountable Executive: Director of Workforce Transformation Capacity for Delivery of Patient Care With increased activity, there are challenges to continue to deliver high quality patient care whilst delivering recruitment of staff to mitigate retention challenges. (Reviewed by the Risk Equalisation Group on 5th May 2015) 4 Revised Corporate s since 11 th March 2015 Risks on the Corporate Risk Register have been reviewed and the action points continue to be implemented, monitored and expanded as appropriate. The following table show the risks where mitigation or further risk identification has resulted in revised current risk ratings but are of a value which requires them to be added to or remain on the Corporate Risk Register. The current status is represented by un-bracketed ratings, whilst those ratings in brackets indicate the rating in place at the time of the previous report. This table excludes those risks which have been removed. Trust Board: Corporate Risk Register Page 5 of 10 Report date: 15/05/2015

6 Description Accountable Executive: Director of Clinical Operations 7 Insufficient income ) Negotiations have commenced for 15/16. 2) Currency and tariff review group in place ) Activity growth for 2014/15 agreed 4) Clinical Ops align with Commissioning plans for 2014/15 5) Fortnightly updates to the Exec Team 6) Monthly updates to the Board 7) The 14/15 APR has been revised in line with the contract income and the associated investments are being re phased in line with resources available Delivery of service following continual rise in activity 1) Implementation of the REAP plans 2) Issues discussed at departmental meetings 4 () (4) () 4 (4) 12 (9) 12 (16) Description Accountable Executive: Medical Director Failure to report on and use safeguarding referral data () (4) (12) 1) Analysis of DATIX data underway during Q1 2015/16 to establish reporting requirements and outputs Trust Board: Corporate Risk Register Page 6 of 10 Report date: 15/05/2015

7 Description Accountable Executive: Director of Clinical Operations RTCs involving PTS vehicles () (2) (6) 1) Four hours of reversing and low speed manoeuvres training will be delivered. Some were delivered in November and December 2014; Driver Training manager will liaise with PTS to identify outstanding staff. 2) Additional training for those individuals who require it will be planned after April ) Black Box technology has been installed into the newer vehicles to identify safe driving Clinical governance of external agencies (2) (2) 1) Ongoing scrutiny of any clinical incident caused by external agency staff 2) Rectification plan underway with one PAP provider ) PAP Desktop Review conducted - outcomes to be reported to the Exec 15 Reduced Training () (4) 9 (4) 9 (12) 1) Ongoing monitoring of training activity against the training plan, with training reports going to WDC as part of minutes. Figures for statutory and mandatory training also included on Corporate Dashboard and data is passed to the Commissioners. 2) Statutory training to be delivered through workbooks and online. ) Cascade methodology employed via CTLs on assessment of key skills 4) Local workshops / development days 5) Revised plan for delivery of Statutory and Mandatory training for 2015/ Safeguarding/MCA training not being delivered in accordance with the agreed safeguarding () (5) 9 (15) 1) Ongoing monitoring of uptake of statutory training for safeguarding in accordance with the TNA. 2) Scrutiny of the ongoing overall training uptake continues as required by weekly monitoring, and formal updates to the RMCGC and Commissioners 205 Medicines management training not being delivered in accordance with the agreed annual TNA () (4) 9 (12) Trust Board: Corporate Risk Register Page 7 of 10 Report date: 15/05/2015

8 Description Accountable Executive: Director of Clinical Operations 1) Escalation of concerns to the RMCGC and Trust Board if trajectories are not achieved within defined timescales. Medicines Management Compliance (4) (4) (16) 1) Business review of Phase 2 of the Medicines Project underway Q1 2015/16. 2) Medicines compliance monitored by the medicines management team and reported to the RMCGC and Lead Commissioners Description Accountable Executive: Director of Finance Safe Transportation of Children () (2) (6) 1) (April 2014) New products have come to market which appear simpler to use than other systems available. It is proposed that these are assessed for suitability. 2) Scoping paper submitted and discussed at the equipment group in October ) Business case will be developed at an appropriate time once the best solution has been determined. 4) Reviewed at driving standards group (Oct 2014). Inability to Retrieve Voice Recordings () (4) (12) 1) IT department to submit a proposal to Clinical Operations on improving system availability to respond to requests for voice recordings. Work ongoing by IT Department anticipated Options Appraisal in Q4 2014/15. 2) Procedure documentation to be reviewed to incorporate all aspects of voice recordings, such as archive, storage, requests etc. ) The voice recording system contractors have advised the Trust that the maintenance of the system is coming to its end of life and reliability issues are unlikely to improve. IT department are therefore obtaining costs for alternatives. 4) Monthly report from the Compliance Department to Lead Managers identified on this risk, the number of voice recordings which could not be found (via summary IWR- 1). 5) Voice recorder scheduled for replacement late Q2/early Q 2015 to resolve Risk 240 Trust Board: Corporate Risk Register Page 8 of 10 Report date: 15/05/2015

9 5 Risks removed from the Corporate Risk Register Risk 166 Failure to develop international best practice: Failure to develop international best practice by leading on innovation (relating to clinical practice). Reviewed by the Risk Equalisation Group on 5th May 2015 and removal requested and include in new risk relating to APR. Removal agreed at RMCGC 07/05/2015. Risk 170 Delivery of Service Development Enablers (SDEs): The Trust may fail to deliver the Service Development Enablers (SDEs) as set out in the Annual Plan in line with the agreed cost, timescales or quality. As enablers, these are key to providing a base for the Trust to deliver its corporate strategy moving forward, and may impact on the Trust's ability to implement its key service developments. Reviewed by the Risk Equalisation Group on 5th May 2015 and removal requested. Removal agreed at RMCGC 07/05/2015. Risk 180 Delay in implementation of trauma system across SEC: SEC Acute Trusts were required to be part of a systematic approach to the management of major trauma with implementation by April The establishment of an agreed defined model for trauma management in Kent was significantly delayed by the network which may result in a fragmented approach to the management of trauma which may lead to delayed or inappropriate treatment. Reviewed by the Risk Equalisation Group on 5th May 2015 and removal requested. Removal agreed at RMCGC 07/05/2015. Risk 18 Potential for adverse patient outcome due to the inability to add new, individual addresses / locations to CAD: Cause: There is no functionality in the CAD system to enable us to: 1) manually add new property address information (e.g. new builds) to the CAD. 2) Amend incorrect property data. ) History markers for vulnerable or violent patients cannot be added if no address is available, which could lead to adverse outcomes for patients and staff and adverse publicity as a result. Effect: EOC staff cannot determine location on maps to enable effective resourcing and this can lead to a delay in a clinical response arriving with the patient. Reviewed by the Risk Equalisation Group on 5th May 2015 and removal requested. Removal agreed at RMCGC 07/05/2015. Risk 190 Non delivery of KMSS NHS 111 service by SECAmb: Failure to deliver the KMSS NHS 111 service throughout the SECAmb area to agreed contractual standards. Reviewed by the Risk Equalisation Group on 5th May 2015 and removal requested. Removal agreed at RMCGC 07/05/2015. Risk 202 CAD performance under peak load: When there are high volumes of calls the CAD system slows down and intermittently freezes therefore there is a delay in dispatching calls during these periods which may affect patient safety and experience. Reviewed by the Risk Equalisation Group on 5th May 2015 and removal requested. Removal agreed at RMCGC 07/05/2015. Trust Board: Corporate Risk Register Page 9 of 10 Report date: 15/05/2015

10 Risk 22 Failure to meet the CQC action plan for Medicines Management: Following a CQC unannounced inspection during December 201, the Trust met the CQC standards required for Outcome 9 Medicines Management, however a small number of actions were identified to improve performance by end Q1 2014/15. Failure to comply will result in an enforcement notice being issued by the CQC. Reviewed by the Risk Equalisation Group on 5th May 2015 and removal requested. Removal agreed at RMCGC 07/05/2015. Risk 227 Risk to patients through unmeasured/potentially inconsistent application of the NHS Pathways triage process in the 999 environment by clinicians and non-clinical call handlers through lack of consistent access to CQI data and now T data since May 2011: Since implementation of NHS Pathways (NHSP) it has been a requirement of the license to the NHSP team that allowed the production of the clinical performance information - ranging from times and distribution of dispositions and insight into how the users individually and collectively utilise the system. There have been ongoing problems both on the SECAmb and NHSP side which has led to only less than 12 months of data being made available and this leaves the team in a situation where we are unable to interrogate the data and ensure the quality and safety of the use of the system. In recent months NHSP has introduce a new system - Immediate Data Tool (T) and this requires CAD development and the provision of a live data feed from the Trust and the purchase of licenses to access the information. It is likely that this will not be implemented until the back end of the three quarter due to business case, development and implementation process required. Reviewed by the Risk Equalisation Group on 5th May 2015 and deemed mitigation is provided in the form of the info.secamb information being used by team leaders and managers to look at distribution of dispositions by operators and continued audit. Removal agreed at RMCGC 07/05/ Update on previous reported risk relating to CCTV at Trust administrative buildings At the last Board meeting a new risk relating to the inability to record and download CCTV at the Trusts main administrative buildings was discussed. A Business Case for all Trust CCTV, which incorporates these sites is being developed. Geraint Davies Director of Commercial Services Trust Board: Corporate Risk Register Page 10 of 10 Report date: 15/05/2015