Foundation Trust Board of Directors 29 March 2017 T Organisational Register Situation At each meeting the Board receives the summary Organisational Register (ORR) highlighting any risk changes and updates since the last Board. Background The executive board first regularly considers and updates the full ORR, with the Quality and Governance Committee and Performance Committee exercising their delegated responsibility from the Board to review, update and gain assurance on their allocated risks. The revised summary ORR is then presented to the Board of Directors for agreement. Assessment There are 23 risks on the current ORR it should be noted that 3 new risks have been identified and added to the ORR and 2 risks have been removed. The current risk level has increased against risk ID 2384. The current risk level has decreased for risk ID 2375 and the current and residual risk levels have decreased for risk IDs 2975 and 2860. The Quality and Governance Committee meeting on 8 th February in it s review of ORR risks noted that following the initial feedback from the CQC further work would need to be undertaken in response to the risks identified. In particular for risk ID 3196 Failure to demonstrate systems and processes that deliver safe practices in community health services it was unclear from the CQC feedback as to which service areas were affected. The committee also agreed that the risk level on risk ID 2567 in relation to learning lessons should be reviewed once the CQC report has been received as there is the potential to reduce the risk level based on the positive report on the learning lessons culture in NHFT received from PWC. All ORR risks will be reviewed against the final CQC report and updated to reflect the impact of recommendations and actions contained within it. The Performance Committee meeting on 1 st March agreed that the risk scores for risk ID 2381 s inherent in new partnership models negatively affect the Trust s ability to deliver its strategy should be reviewed by the Exec. team to provide the committee with assurance that appropriate mitigations were in place in response to this risk. The committee also discussed and identified a number of potential risks for inclusion on the finance directorate risk register and where required escalation onto the ORR.
Directorate level significant risks 8 risks are currently listed. At the January Board update 9 risks were recorded - 1 has now reduced ( ID 2829 Corby Community Hospital), 1 has been resolved ( ID 2697 HMP Littlehey) and 1 new risk identified ( ID 3211 Beechwood Ward). Recommendations The Board is asked to note and agree the updated ORR. Governance Table Paper sponsored by: Chris Oakes Director of HR & OD Paper authored by: Tina Perkins Health and Safety Manager, Trust Policy Lead, MDSO Date submitted: 15.3.17 DIGB Q strategic alignment*: Develop Innovate Grow Build Quality Organisational Register Considerations: Bi-monthly review and update of ORR risks FOMI considerations: None believed to apply Equality considerations: None believed to apply
Organisational Register Chris Oakes, Director of HR & OD March 2017
Executive summary New risks have been added for: ID 3195 Owner Director of Nursing/Chief Operating Officer Health based place of safety fails to meet regulatory requirements for safety and privacy and dignity added in response to initial CQC inspection feedback. ID 3196 Owner Director of Nursing/Chief Operating Officer Failure to demonstrate systems and processes that deliver safe practices in community health services added in response to initial CQC inspection feedback. ID 3197 Owner Finance Director The Trust is unable to deliver its Financial Plan and support STP implementation 2017/19 s removed from ORR (greyed out in report): ID 2565 Owner Chief Operating Officer Compliance action for seclusion works now complete ID 2772 Owner Medical Director Capability and capacity to deliver research studies risk now managed Updates to risk status: ID 2375 Owner Finance Director The Trust is materially unable to deliver its financial plan 16/17 based on the current financial run rate and projections the Trust expect s to achieve the finance target - the likelihood of this risk being realised has consequently reduced. ID 2384 Owner Director of Nursing Regulatory non-compliance with CQC/Ofsted jeopardises the Trust s ability to deliver its strategy likelihood increased to reflect initial CQC inspection feedback ID 2860 Owner Finance Director/COO Regulatory non-compliance with IAPT targets jeopardises the Trust s risk rating likelihood reduced based on meeting the 6 and 18 week targets on a consistent basis to comply with NHSI requirements. ID 2975 Owner Director of HR & OD Impact of multiple staff consultations current and residual risk level reduced as the significant number of consultations have been completed. Whilst there will still be future consultations there should not be the significant numbers and work has continued to improve the relationship with staffside.
Summary of current organisational risk 5 CIPs/quality Health based place of safety Safe practice in community health Safeguarding Acute Outflows VTE/NEWS Insufficient medical staffing levels Unable to deliver financial plan 16.17 Regulatory noncompliance Workforce capacity/ capability Unable to deliver financial plan 17.19 Consequence 4 Failure to support innovation Demand pressures Healthier Northamptonshire New partnership models Poor practice Learning from lessons Regulatory noncompliance IAPT Better Care Fund PPM - NHSPS properties Staff consultations EPRR Clinical audit 3 2 1 Likelihood
Summary of residual organisational risk (after actions completed) 5 Safeguarding Regulatory noncompliance VTE/NEWS Acute Outflows CIPs/quality Unable to deliver financial plan 16.17 Workforce capacity/ capability Insufficient medical staffing levels 4 Failure to support innovation Safe practice in community health Demand pressures Poor practice Health based place of safety Healthier Northamptonshire Better Care Fund New partnership models Unable to deliver financial plan 17.19 Consequence 3 Clinical audit EPRR Learning from lessons Staff consultations Regulatory non-compliance IAPT 2 PPM - NHSPS properties 1 1 2 3 4 5 Likelihood
tracking over time Performance Committee risks ID 2381 Title Owner @ Nov Strategic theme 1 Develop in Partnership s inherent in new partnership models negatively affect Trust s ability to deliver its strategy Director of Strategic Partnerships @ Jan @March Residual 12 12 12 12 Strategic theme 2 - Innovation 2377 Failure to support innovation Medical Director 8 8 8 4 2772 Capability and capacity to deliver research studies Medical Director 16 16 16 8 Strategic theme 4 Build a sustainable organisation 2375 The Trust is materially unable to deliver its financial plan 25 25 15 15 Finance Director 16/17 2376 The Trust is materially unable to manage demand 12 12 12 8 Chief Operating Officer pressures 2378 Implementation of STP negatively affects the Trust s Director of Strategic 12 12 12 12 ability to deliver its strategy Partnerships 2379 2860 3197 2562 The BCF negatively affects the Trust s ability to deliver its strategy Regulatory non-compliance with IAPT targets jeopardises the Trust s risk rating The Trust is unable to deliver its Financial Plan and support STP implementation 2017/19 Strategic theme 5 - Quality Lack of emergency preparedness results in major service failure Chief Operating Officer/Finance Director Finance Director/COO Finance Director Director HR & OD 16 16 16 12 20 20 12 9 20 (new) 12 12 12 6 2761 Acute outflows Chief Operating Officer 15 15 15 10 2972 Lack of assurance for planned preventative maintenance (PPM) on properties leased with NHSPS Finance Director 16 (new) 12 16 4
tracking over time Quality and Governance Committee risks ID 2385 Title Owner @ Nov Strategic theme 3 Grow our staff capability The Trust is unable to maintain the right workforce capability and capacity to deliver its strategic plan Director of HR & OD/ Director of Nursing/Medical Director @ Jan @ March Residual 20 20 20 15 2771 Insufficient medical staffing levels Medical Director 20 15 15 15 Strategic theme 5 - Quality 2383 The Trust maintains an insufficient balance between CIPs and Director of Nursing/Medical 10 10 10 10 quality Director 2384 Regulatory non-compliance with CQC/Ofsted jeopardises the 10 10 15 10 Trust s ability to deliver its strategy Director of Nursing 2386 The Trust fails to safeguard children and adults appropriately Director of Nursing 15 15 15 10 2387 The Trust fails to identify and act on poor practice Director of Nursing (jointly 12 12 12 8 with Director of HR & OD) 2563 Clinical audit plan priorities may not match safety risks Medical Director 12 15 15 3 2565 Compliance action of seclusion Chief Operating Officer 15 9 3 2567 Compliance action for improving learning lessons Director of Nursing/COO 12 12 12 6 2833 2975 3195 3196 Non-compliance with VTE/NEWS assessment levels Impact of multiple staff consultations Health based place of safety fails to meet regulatory requirements for safety and privacy and dignity Failure to demonstrate systems and processes that deliver safe practices in community health services Director of Nursing/Medical Director Director of HR & OD Director of Nursing/Chief Operating Officer Director of Nursing 15 15 15 10 9(new) 9 6 4 10 (new) 10 (new) 8 4
Directorate level significant risks In this review period there are 8 risks recorded as significant on Directorate level risk registers IM&T Responsible Director Finance Director ID 2810 Medication recording in the shared SystmOne record - Deployment of eprescribing is out of scope for this deployment. There is therefore no clear way to record medication that the patient is prescribed by mental health services that would be obvious to other units that have access to the shared record. Funding to address this issue was identified through the Capital Programme for 16/17; however this was classified as Amber and therefore not released. Mid year review of Capital Programme has identified some capital flexibility and e-prescribing has now been added to the Capital Scheme list for 2017-18. Estates management Responsible Director - Finance Director ID 2859 High parking demand across a number of sites issues relating to parking leading to increased risk of injury through blocking of walkways and reduced visibility, obstruction of other vehicles, damage to vehicles, violence and aggression, stress, missed appointments and reputational damage. The travel survey closed at the end of December. A parking strategy paper was presented and approved at the Performance committee on March 1 st. Adult services Therapies Responsible Director - Chief Operating Officer ID 2105 Diabetic foot and high risk podiatry service due to the increase in the active case load with no increase in capacity there are insufficient staff with the correct level of skills and competencies to manage the referrals requiring 24-48 hr appointments only 72% on average since April are being seen within timescales. There is a known increase of people with a diabetes diagnosis in the county of approx. 12% year on year with no additional uplift for commissioning the services by the CCG. Business case submitted to CCG March 2016 and escalated for resolution in March and August. Clinical senate has reported to commissioners to receive a demand and capacity review as recommended by the clinical senate report. As part of the contract the CCG has agreed to consider any recommendations from the report. IM&T Responsible Director Finance Director ID 2977 The current telephone provision at Rectory Road is unreliable and at risk of failure. Due to its age support is not available. Project brief with estimated replacement costings to replace the current provision with VOIP requires approval from NHFT. Mid year Capital Programme review has identified some capital flexibility and this has now been approved. Adult Services - Community beds and Rehab Responsible Director - Chief Operating Officer ID 3148 An increased number of patients are being admitted from the local acute hospitals who are outside of community hospital criteria, for example acutely unwell and not matching the initial referral documentation. This presents a clinical risk to the patient as the community hospital may not be able go respond appropriately to needs. Should this happen the patient would be immediately transferred back to acute hospital. Incidents are being monitored and reported to commissioners via the Trust quality schedule. Adult Services Unplanned and Planned Responsible Director Chief Operating Officer ID 3165 and 3166 - Increased number of patients discharged from local Acute Hospitals without complete referral information to service as well as patients referred via trusted assessor process (DTA) for which clinical information differs from clinical presentation of patients at initial assessment who are often found to be clinically unstable and unfit to be left at home. If patient found to be so unwell that can not be safely managed at home then patients would be returned to the acute trust to mitigate clinical risk to patient. Update for risk IDs 3148, 3165 & 3166 - Meetings held with acute hospital colleagues to review incidents and identify actions to mitigate further occurrence. Issues also highlighted to CCG quality team who will be providing support to address issues. Additional systems put in place within NHFT to mitigate risks to patients to include an additional check completed prior to admissions to community beds
Directorate level significant risks - new Adult Services - Community beds and Rehab, Beechwood Ward Responsible Director - Chief Operating Officer ID 3211 Temperature of the room drugs are stored in is above guidelines which may have detrimental effect on the medicines. Additional cooling mechanisms now in place to reduce temperature. Estates are reviewing the possibility of a more permanent solution and in the mean time staff are regularly (daily) checking the temperature of room and escalating to pharmacy as necessary.
Appetite Sept. 2016 - Matrix based on Good Governance Institute Appetite Matrix for NHS organisations levels 0 1 2 3 4 5 Key elements Avoid Avoidance of risk and uncertainty is a Key Organisational objective Minimal (ALARP) (as little as reasonably possible) Preference for ultra-safe delivery options that have a low degree of inherent risk and only for limited reward potential Cautious Preference for safe delivery options that have a low degree of inherent risk and may only have limited potential for reward. Prepared to accept possibilityof some limited financial loss.vfm still the primary concern but willing to consider other benefits or constraints. Resources generally restricted to existing commitments. Open Willing to consider all potential delivery options and choose while also providing an acceptable level of reward (and VfM) Seek Eager to be innovative and to choose options offering potentially higher business rewards (despite greater inherent risk). Mature Confident in setting high levels of risk appetite because controls, forward scanning and responsiveness systems are robust Financial/VFM Avoidance of financial loss is a key objective. We are only willing to accept the low cost option as VfM is the primary concern. Only prepared to accept the possibility of very limited financial loss if essential. VfM is the primary concern. Prepared to invest for return and minimise the possibility of financial loss by managing the risks to a tolerable level. Value and benefits considered (not just cheapest price). Resources allocated in order to capitalise on opportunities. Investing for the best possible return and accept the possibility of financial loss (with controls may in place). Resources allocated without firm guarantee of return investment capital type approach. Consistently focussed on the best possible return for stakeholders. Resources allocated in social capital with confidence that process is a return in itself. Compliance/ regulatory Innovation/ Quality/Outcomes/ Patient Benefit Play safe, avoid anything which could be challenged, even unsuccessfully. Defensive approach to objectives aim to maintain or protect, rather than to create or innovate. Priority for tight management controls and oversight with limited devolved decision taking authority. General avoidance of systems/technology developments. Want to be very sure we would win any challenge. Similar situations elsewhere have not breached compliances. Innovations always avoided unless essential or commonplace elsewhere. Decision making authority held by senior management. Only essential systems / technology developments to protect current operations. Limited tolerance for sticking our neck out. Want to be reasonably sure we would win any challenge. Tendency to stick to the status quo, innovations in practice avoided unless really necessary. Decision making authority generally held by senior management. Systems/ technology developments limited to improvements to protection of current operations. Challenge would be problematic but we are likely to win it and the gain will outweigh the adverse consequences. Innovation supported, with demonstration of commensurate improvements in management control. Systems / technology developments used routinely to enable operational delivery Responsibility for non-critical decisions may be devolved. Chances of losing any challenge are real and consequences would be significant. A win would be a great coup. Innovation pursued desire to break the mould and challenge current working practices. New technologies viewed as a key enabler of operational delivery. High levels of devolved authority management by trust rather than tight control. Consistently pushing back on regulatory burden. Front foot approach informs better regulation. Innovation the priority consistently breaking the mould and challenging current working practices. Investment in new technologies as catalyst for operational delivery. Devolved authority management by trust rather than tight control is standard practice. Reputation No tolerance for any decisions that could lead to scrutiny of, or indeed attention to, the organisation. External interest in the organisation viewed with concern. Tolerance for risk taking limited to those events where there is no chance of any significant repercussion for the organisation. Senior management distance themselves from chance of exposure to attention. Tolerance for risk taking limited to those events where there is little chance of any significant repercussion for the organisation should there be a failure. Mitigations in place forany undue interest. Appetite to take decisions with potential to expose the organisation to additional scrutiny/interest. Prospective management of organisation s reputation. Willingness to take decisions that are likely to bring scrutiny of the organisation but where potential benefits outweigh the risks. New ideas seen as potentially enhancing reputation of organisation. Track record and investment in communications has built confidence by public, press and politicians that organisation will take the difficult decisions for the right reasons with benefits outweighing the risks. APPETITE NONE LOW MODERATE HIGH SIGNIFICANT