Risk Management Report and Board Assurance Framework - Q2 2014/15 Ramona Duguid, Acting Director of Governance

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1 Report to Trust Board of Directors Date of Meeting: 25 November 2014 Enclosure Number: 19 Title of Report: Author: Executive Lead: Responsible Sub- Committee (if appropriate): Executive Summary: Risk Management Report and Board Assurance Framework - Q2 2014/15 Ramona Duguid, Acting Director of Governance Gail Naylor, Director of Nursing and Midwifery Risk and Assurance Committee The Risk and Assurance Committee has been established now for 12 months. Progress continues to be made with embedding the systematic approach to risk management across the Trust. This report to the Board has been further developed to show greater transparency and connectivity to the Corporate Risk profile for the Trust. This report also summarises the outputs from the Risk and Assurance Committee and proposes changes to the Strategic Risks contained within the Board Assurance Framework (BAF) for Q2 of 2014/15. The updates to the BAF have been reviewed by the Executive Directors in order to provide greater focus on the core strategic risk issues facing the organisation. The BAF has also been refreshed to allow greater clarity on the connectivity with specific Corporate Risks. The updated BAF is attached to Appendix 1 of this report and a summary overview of the corporate risk register is attached at Appendix 2. Board Assurance Framework Reference: All 2014.docx Page 1 of 9

2 Risk Rating (high, medium, low risk) and any recommended changes to risk rating: Compliance, legal and national policy regulatory requirements: Financial Implications: Actions required by the Board: N/A This report includes the risks to delivery of NHS Constitutional standards and CQC Regulatory Compliance. The report includes the strategic financial risks facing the Trust. To approve: To note: Discussion and decision Where the Board is made aware of key points but no decision required For information: For reading and consideration and for discussion by exception only The Trust Board are requested to: APPROVE the updates to the BAF for Q2 2014/15 and seek any further assurances on the mitigation plans in place. NOTE the Corporate Risk Register position as at Q2 2014/15. NOTE the key outputs from the Risk and Assurance Committee in October and November Data quality: Source: Ulysses System ( Risk Registers) Individual Director Updates to the BAF Validated by: Ramona Duguid, Acting Director of Governance Date: 16 June docx Page 2 of 9

3 TRUST BOARD RISK MANAGEMENT REPORT Q2 2014/15 1. INTRODUCTION This report summarises for the Trust Board the outputs from the review of the Corporate Risk Register by the Risk and Assurance Committee in October and November 2014 and proposes changes to the Board Assurance Framework for Q2 2014/ STRATEGIC RISK PROFILE AND BOARD ASSURANCE FRAMEWORK The Trust has many risks associated against the delivery of its objectives, which are identified through the risk management process within the clinical business units and escalated through the review of the risk registers via the Risk and Assurance Committee. Risks graded as 15 and above are automatically placed on the Corporate Risk Register, which is reviewed by the Executive Management Team and Risk and Assurance Committee. It is important therefore that the BAF is focussed explicitly on the principal risks that directly affect the ultimate achievement of the organisations strategic objectives. It is also important to highlight that the Trust has been on a significant journey of improvement in relation to its risk management processes and progress has been made in a number of core areas during the last 18 months. It is standard practice to have in place an assurance framework that captures the principal risks affecting the delivery of the strategic objectives; however the format and process of updating the BAF varies significantly across NHS organisations. It is also important to recognise the criticisms and failings of organisations where their assurance frameworks have lacked focus and grip on the core risk issues facing the organisation and a lack of connectivity between the risks underpinning these issues across individual services and risk registers. The Trust is operating in special measures; therefore it is essential that the Board has a clear grip and focus on the key strategic risks facing the Trust. It is equally important that the Board has regular review of the Corporate Risk Register and the connectivity these risks have to specific strategic risks. 2.1 Updated BAF The BAF has therefore been updated with the Executive Directors and is attached at appendix 1 of this report. The updates made are summarised in the key points below docx Page 3 of 9

4 The assessment of strategic risks facing the organisation are fundamentally linked to workforce (staffing levels), the ability to develop and deliver a sustainable clinical and financial future, delivery of NHS Constitutional standards and regulatory compliance (linked to special measures and Chief Inspector of Hospitals). Many of the core risk items, cross over and effect multiple strategic objectives. The BAF has been updated to reflect this multiple effect across strategic objectives. The layout of the BAF has been improved to show in greater clarity the additional actions being undertaken to address the gaps in control or assurance. This is an important section of the BAF to ensure the Board scrutinises and challenges the actions in place to ultimately achieve the target risk position. It is important to recognises that there are multiple corporate risks (those graded 15 and above) that link to an overarching strategic risk, for example workforce has multiple corporate risks within the clinical business unit teams relating to both medical and nurse staffing. It is therefore important that the Board has assurance on these risks items and the mitigation plans in place. The risk management report to the Board has been expanded to provide greater clarity on the Corporate Risks and their connectivity with the strategic risk position of the organisation. This allows the Board to have a greater understanding of the risk profile of the organisation. In addition, it also allows greater clarity amongst executive directors on the corporate risks which link to their BAF related items. 2.2 Strategic Risk Profile The Trust has nine principal risks areas identified on the BAF which relate to the following core areas: Ref 1 - Special measures new risk The risk of not being taken out of special measures has been added to the updated BAF as a new risk in its own right and is a graded as a high risk. The mitigations in place link to the delivery of the plans to address the inadequate areas identified by the Chief Inspector of Hospitals and improving the significant workforce challenges across the Trust, which link to the medium to longer term changes in line with the clinical way forward for acute care. Ref 2 - Delivery of the clinical strategy updated existing risk The development of the clinical strategy related risk has been updated on the BAF but remains a high risk. The Trust has published the clinical way forward and a range of engagement events are planned for November and December with the local population. The independent review for maternity has commenced and an independent assessment on the anaesthetic workforce assessment has been completed docx Page 4 of 9

5 Programme governance arrangements have been developed internally but it is recognised that there are gaps with capacity in certain areas, which will require close monitoring by the Executive Management Team. Working with system wide partners is in place to ensure plans are aligned. Ref 3 - Delivery of NHS Constitutional standards updated existing risk The three core risk areas in relation to delivery of the A&E 95% standard, 18 weeks referral to treatment and cancer access standards remain core risk items in relation to delivery of the NHS Constitutional standards. Progress has been made with both 18 weeks and cancer and the risk position has reduced to a medium level. The emergency care standard for A&E remains a high risk area and increased system wide action and escalation has been implemented during recent weeks and will remain in place until improvement can be demonstrated. Ref 4 Regulatory Compliance updated existing risk The risks in relation to regulatory compliance have been updated into two core risk areas. The first is in relation to the delivery of the Chief Inspector of Hospitals improvement plan and the second is in relation to general compliance with the CQC essential standards. Both risks are graded as medium due to the controls in place and further actions are being implemented to work on the specific gaps in assurance and control. Ref 5 Workforce updated existing risk The risks in relation to the workforce have been updated to make explicit reference to the risk regarding medical and nurse staffing levels as well as the overall capacity and capability of the workforce to deliver the Trust priorities and associated change programmes. This is one of the highest scoring risk items on the BAF and has a number of gaps in control and assurance, where further actions are being implemented. The workforce related risk issues link to all of the Trusts strategic objectives. Ref 6 Culture updated existing risk The risk that the Trust does not develop an open and transparent culture remains a key strategic risk item for the Board. This is potentially further compounded by the negative impact of the clinical way forward with certain staff groups and ongoing whistle blowing concerns from individual members of staff. A staff engagement plan is in place in relation to the clinical way forward and an organisational development plan is in place. Ref 7 Patient Safety new risk The previous BAF had a number of individual patient safety risks which have been reviewed to provide greater clarity on the key strategic gaps in control and assurance regarding patient safety docx Page 5 of 9

6 The key gaps in control and where further action is required relates to the systematic approach to quality being embedded, including the associated data collection and audit processes. The capacity to deliver the priorities in relation to safety and quality is also highlighted as a gap in control. A sign up to safety campaign has been developed which will assist with the focus on the key priorities for safety and reducing harm. Ref 8 Estate new risks Two new strategic risks have been added regarding the management of the PFI contract at the Cumberland Infirmary and the opening of the new West Cumberland Hospital. The PFI related risk is rated as high due to the associated impact with relation to cleaning and maintenance standards. The risk regarding the new build at Whitehaven is low. Ref 9 Financial stability updated existing risk The Trust has had a number of finance related risks which have been updated. This risk is the other very high related risk on the BAF. A financial recovery plan is in place in order to achieve the overall deficit control position but challenges in relation to locum and agency expenditure and the ability to realise cost improvement benefits remain key gaps in control and assurance. The updated BAF is attached at Appendix 1 of this report. 3. CORPORATE RISK REGISTER PROFILE NOVEMBER 2014 The Corporate Risk Register includes any risks from the Clinical Business Units or Corporate Functions which score greater than 15 in their assessment. This is to ensure that there is a clear escalation process in place for the highest scoring risks across the organisation. The Corporate Risks were reviewed by the Risk and Assurance Committee in October and November The table below summarises the number of Corporate Risks across the business units and corporate functions: Business Unit/Corporate Function Total number of corporate risks Emergency Care and Medicine 9 Emergency Surgery and Elective Care 8 Child Health 4 Cancer Services and Clinical Support 26 Estates and Facilities 7 Human Resources 4 Finance 3 IM&T 0 TOTAL docx Page 6 of 9

7 3.1 Corporate Risk Profile Q2 The illustration below summarises the corporate risk profile, across the clinical business units and corporate functions in relation to the core risk domains of safety and quality, workforce, finance and estates as at Q2. Electronic Prescribing Safer medicines training 62-day cancer pathway Medicines Reconciliation Medical Devices Training Recruitment premium for medical staff Breast Consultant Radiology Capacity Blood science cover at WCH Histopathologist consultant cover Patient flow Safer medicines homecare Access to dermatology Transfer sick Children Case note availability Pharmacy capacity Opening of escalation beds Slips, Trips and Falls Long term service resilience Second theatre for obstetrics Inadequate Community Paediatrics 18 WKs RTT Diagnostics ERCP procedures 18 Wk RTT 62 Day Cancer Chemotherapy Drugs Emergency response WCH Radiotherapy service Safety and Quality Appraisal completion Workforce Medical Locums/Agency Medical cover all grades in medicine Nurse Staffing Radiologist recruitment Nurse Staffing Appraisal completion Acute medical cover WCH Recruitment of electrical trade staff Junior doctor teaching WCH Anaesthetic cover obstetrics WCH Colour Ref: Medicine Surgery Clinical Support Child Health Estates Finance HR Cost pressures I&E position Failure to deliver CIP CIP Failure to deliver CIP Failure to deliver CIP Finance & Infrastructure Estates, Equipment & Environment Mobile X-ray equipment age and failure Single IV radiology facility Failure histology tissue machine Centrifuges for blood transfusion 2014.docx Page 7 of 9 C Arm Endoscopy Failure Raymond Lamb embedding Centres Failure frozen plasma freezer Breakdown and age X-Ray Rooms Working at height on new build Fire safety including medical records PACS replacement overdue Maintenance Standards at CIC Cleaning Standards at CIC

8 3.2 Outputs from Risk and Assurance Committee (including escalation) The table below summarises the risk items where further review and action has been requested by the Risk and Assurance Committee: Risk issue Nurse staffing NICE and Clinical Guidelines Safer Medicines Clinical support equipment related items Review and Action required The weekly nurse staffing meetings, led by the Director of Nursing & Midwifery are to review the nurse staffing risk assessments to ensure the high risk ward areas where significant gaps in nursing cover are consistent are fully reflected in the gaps in control and assurance. The new risk in relation to the opening of escalation beds requires further detail on mitigations in place, which need to be cross reference to the nurse staffing risks for those ward areas. The updated risk assessment in relation to clinical guidelines (graded as amber) and reviewed by the Safety and Quality Committee in November should be fully reflected in the specialty level risk registers for each of the clinical business units, following review by the Clinical Directors. Further detail on the programmes of work to improve medicines safety is required on the medicines safety related risk items. The risk grading on the clinical support equipment related items has been challenged for further review in terms of the grading but also the timescales in place for replacement as part of the capital replacement programme. At the November meeting of the Risk and Assurance Committee a full review of all of the risk registers was undertaken. Feedback has been given to the Clinical Business Units on the status of their registers and where further improvements are required in terms of completeness and assurance that controls are working. All Business units are demonstrating improved regular review of their risk registers, which now needs to be communicated back through the ward teams and departments. The next meeting of the Risk and Assurance Committee is in January 2015 where the improvements requested will be formally reviewed. The committee also approved an update to the risk register template to allow a specific action/risk treatment section to be added for each risk, which will be implemented during December for all registers. 4. CONCLUSION The Risk and Assurance Committee continues to make good progress in ensuring that there is regular review and challenge of the Trust wide risk register, with a specific focus on the Corporate Risks docx Page 8 of 9

9 This report summarises for the Board the strategic risks facing the organisation which are detailed in the supporting Board Assurance Framework and the highest scoring Corporate Risks arising from the clinical business units and corporate functions. The governance team are working on the priority areas of work for 2015/16, which will include a greater focus on assurance levels and sources, residual risks and updating the Ulysses system across the organisation to allow greater access and sharing of information on the main risk management information system. 5. RECOMMENDATIONS The Board is requested to: APPROVE the updates to the BAF for Q2 2014/15 and seek any further assurances on the mitigation plans in place. NOTE the Corporate Risk Register position as at Q2 2014/15. NOTE the key outputs from the Risk and Assurance Committee in October and November Ramona Duguid ACTING DIRECTOR OF GOVERNANCE Supporting appendices: Appendix 1 Board Assurance Framework Q2 2014/15 Appendix 2 Corporate Risk Register Summary Q2 2014/ docx Page 9 of 9