Report Title: Executive/NED Lead: Report author(s): Previously considered by: Board of Directors Tuesday, 31 October 17 Board Assurance Framework & Corporate Risk Register Ann Alderton, Company Secretary Ann Alderton, Company Secretary Quality and Risk EMC; F&P,POD & QPS Board Assurance Committees Approval Discussion Information Assurance Executive summary Purpose The Board Assurance Framework (BAF) sets out the strategy objectives, identifies risks in relation to each strategic objective along with the controls in place and assurances available on their operation. The BAF can be used to drive the board agenda. The Corporate Risk Register (CRR) is the corporate high level operational risk register used as a tool for managing risks and monitoring actions and plans against them. Used correctly it demonstrates that an effective risk management approach is in operation within the Trust. Status Update since the previous meeting (refer to EMC report) BAF There are risks in the BAF, of which 9 are red, as follows. There have been no changes to the risk scores since the previous report but the narrative has been updated to reflect the most recent assurance activity and to reflect Board Assurance committee discussions, as appropriate: Risk Unless we work with our health and social care partners to understand flow across the system, then we may have inadequate arrangements in place to manage demand (activity) which may impact on the system resilience and internal efficiencies, impacting on delivery of contractual performance [Up from previous report due to deteriorating trajectories] If we do not have in place effective organisational financial management, then we may not be able to fully mitigate the variance and volatility in financial performance against the plan leading to failure to deliver the control total, impact on cash flow and long term sustainability as a going concern [No change] Failure to achieve quality and cost improvements in Pathology leading to suboptimal service and impacting on patient care and relationship with partners [Up from mathematical error] If we do not fully engage our staff on the improvement journey, then they may fail to make a positive contribution to change, which may limit the sustainability of improvements made [No change] If we do not resource our nurse staffing rotas at ward/ department level then we will long term impact on staff resilience and poor retention of staff [No change] If we do not resource our medical staffing rotas at ward/ department level then we will long term impact on staff resilience and poor retention of staff [ No change] If we do not have in place robust processes for the recording of activity, then we may have inaccuracies for clinical use and reporting of activity, which may lead to suboptimal care for our service users due to information gaps regarding patient Risk Score 25
diagnosis, care and treatments, tracking of patient pathways and coding inaccuracies [No change] If we do not improve the quality of care to patients sustainably and consistently as a result of gaps in key roles and poor engagement, leadership, capacity and capability, we will fail to provide good care, fail to achieve regulatory compliance and will suffer reputational damage. [No change] If we do not transform through strategy and operational change management then we will lose grip on our long term sustainability [Risk revised down from ] If we do not resource our AHP staffing rotas at ward/ department level then we will long term impact on staff resilience and poor retention of staff [No change] If we do not have in place a suitably qualified and experienced leadership team (across sub board levels, including Divisional and Clinical Delivery Group (CDG) Leadership, then we may fail to deliver the required improvement at pace, with the potential for continued or escalated regulatory enforcement action [No change] If we do not have effective accountability and escalation arrangements, the executive team and the board may be unaware of important risk issues, significant control weaknesses and patient safety concerns in the rest of the organisation. This may lead to failure to act to protect patient safety, failure to learn as an organisation and potential regulatory intervention. [No change] 15 Corporate Risk Register There are risks in the Corporate Risk Register with a current score of and above, of which four are red, as follows: Risk A failure to comply with the National Safety Standards for Invasive Procedures (NatSSIPs) recommendations issued by NHS England in September 15, caused by a lack of engagement and escalation by the Divisions, may result in the Trust being non-compliant with National Guidance, compromise patient safety and negatively impact the Trusts reputation [New] A failure to ensure that sufficient staff are recruited and retained to meet the requirements of increased activity and acuity requirements, caused by inefficient recruitment processes and insufficiently embedded retention schemes, may lead to increased staff sickness related to low staffing levels thereby increasing the vacancy factor and the inability to deliver high quality care [No change] A failure to have sufficient trained staff across the organisation to provide physical intervention (restraint) caused by an insufficient number of staff trained may lead to potential patient harm if intervention is performed incorrectly or not delivered as required in a timely manner [New] A failure to ensure the safe management of cellular pathology specimens from source through to delivery to the lab, caused by a lack of standardised process of management across the trust, may lead to potential risk to patient safety [No change] A failure to have a robust system for identifying and updating policies/procedural documents requiring review in a timely manner may cause staff to act on inaccurate information resulting in potential regulatory and contractual sanctions [No change] A failure to not fully comply with Health and Safety (Sharps Instruments in Health Care) Regulations 13 caused by failing to trial sharps safety devices in all areas of the Trust and in particular theatres and children s wards, not complying with environmental legislation when disposing of sharps boxes not assembled or signed correctly and staff members failing to comply with good practice and training may lead to non-compliance resulting in HSE enforcement notices and financial loss and 2 Risk Score 15
injuries occurring due to poor disposal of sharps and poor practice by staff members [No change] A failure to ensure that the Trust maintains a rolling programme for medical equipment replacement, including those at high risk of failure such as the interventional radiology equipment, caused by financial constraints and an ineffective equipment management system, may lead to staff using equipment that is no longer fit for purpose and increases the risk to patient safety. This in turn will impact upon the Trust s compliance against external regulatory requirements, which may lead to regulatory action [Reviewed risk reduced] A failure to consistently sustain the end of life care for all caused by a lack of mandatory face-to-face training for clinical staff determined by the End of Life Education Strategy may lead to poor patient experience, lack of advanced care planning and lack of ability to discharge patients rapidly to their preferred place of care [Reviewed and re-worded] A failure to ensure that robust governance processes are in place to provide assurance of risk mitigation, patient safety improvements, learning from incidents, complains and claims, including the delivery of policies and procedures that meet national best practice, caused by insufficient scrutiny and review of existing practice due to insufficient frameworks and guidance in place, may lead to the Trust being non-compliant with CQC Fundamental Standard and 17 [No change] A failure to ensure that staff are supported in the raising of concerns within the Trust, caused by colleagues lacking confidence that concerns will be answered and acted upon in a robust and timely fashion, may lead to on-going whistleblowing cases being made externally to the organisation. This may subsequently lead to a sustained increase risk profile and increased scrutiny, with potential sanctions placed upon the Trust against the failure to comply with Health and Social Care Act regulation [No change] A failure to ensure that learning from incidents and serious incidents is embedded consistently across the Trust caused by immature developed governance within the Divisions, may lead to a reactive response to patient safety concerns, a failure to ensure systems and processes are in place to prevent recurrence, thereby increasing the risk of patient harm occurring [No change] A failure to provide service contract for the existing decontamination machines (provided by Cantel) caused by the end of life of the current machines and the inability to provide a service contract for the machine whilst transitioning between old to new contracts as part of the new decontamination facility. This could Gastro, GI services, ENT and Urology [Reviewed and risk reduced] Layer Marney Ward A failure to provide safe and effective care caused by poor leadership and critical nursing staff shortages may lead to avoidable serious incidents, poor patient experience, increased distress to relatives and increased complaints in additional to a poor staff experience leading to a high attrition rate and difficulty in recruiting substantive nursing staff [New risk] Pharmacy Building a failure to ensure that the Pharmacy building is of a suitable standard to prepare medicines for injection by aseptic methods, caused by insufficient planning and identification of the extent of building degradation with associated financial constraints when action has been required, may lead to the Trust losing MHRA accreditation and license to manufacture, which will subsequently lead to disruption in patient care delivery, subsequent financial penalties and a negative reputational impact on the Trust being able to deliver comprehensive medication services [New risk] A failure to ensure that both NICE guidance and quality standards are reviewed, responded to, actioned and evidenced, caused by historical backlogs of NICE guidance inactivity, competing priorities and a lack of rigour in ensuring such action 3
has been taken, may lead to treatments not being reviewed in line with national best practice, staff being unclear as to what action is required to comply with requirements and patients not being provided with the most appropriate treatments for their conditions [Reviewed risk reduced] Action Required of the Board of Directors The Trust Board is asked to note the BAF and Corporate Risk Register risks listed above, the current status of both documents and future developments. Board Committees are encouraged to update their assurance maps with the above risks so as to ensure that their forward plans are reflective of the principal strategic risks and main operational risks to the Trust Link to Strategic Objectives (SO) SO1 SO2 SO3 Acting in the best interests of every patient every day Supporting our Workforce to look after every patient, every day Achieving financial sustainability and organisational resilience To deliver care in the right place at the right time in line with national best practice To ensure a positive patient experience at every contact by providing safe, effective, kind and compassionate care To achieve sustainable quality improvements in the delivery of care To deliver a positive patient-centred culture of great care for patients To engage, support and develop staff to achieve their potential To train and support all staff to take personal responsibility and accountability for their actions and the actions of others to drive organisational success To develop constructive relationships with partner organisations to deliver sustainable and effective care for patients To deliver consistently and sustainably against national and local priorities To maximise value for money in delivering healthcare in our locality Please tick Risk Implications for the Trust (including any clinical and financial consequences) Trust Risk Appetite If we do not have effective risk management arrangements, we may fail to predict, plan and prepare for potential threats to the organisation s objectives and this may jeopardise their delivery Compliance: The Board has a cautious risk appetite when it comes to compliance and regulatory issues, especially in relation to delivery of safe, high quality care. It will only challenge them if there is strong evidence or argument to do so Legal and regulatory implications (including links to CQC outcomes, Monitor, inspections, audits, etc) Financial Implications Risk Management is part of the Well-led Framework for assessing Boards of Directors There are no financial implications 4
Equality and Diversity There are no E&D implications 5