SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Meeting … · The 2016-17 BAF Quarter 2 updateis...

SOUTH WARWICKSHIRE NHS FOUNDATION TRUST

Meeting Board of Directors

Date 5 October 2016

Subject Board Assurance Framework and Risk Quarterly Report

Enclosure M

Nature of item For information For approval For decision

Decision required (if any)

1. To agree the closure of one risk (Risk ID 1075) 2. To agree the addition of two risks (Risk ID 1080 & 1079) 3. To approve the Quarter 2 Board Assurance Framework for 2016-17

8-12 (Dark Amber) and 15-25 (Red) 4. To receive the Quarter 2 risk register 15-25 (Red)

General Information

Report Authors Executive Team Collated By Joanne Beales, Lead Risk, Health & Safety

Adviser Lead Director Glen Burley, Chief Executive

Received or approved by

Meeting Risk Management Board Date 12 September 2016

Resource Implications

Revenue Capital Workforce Use of Estate Funding Source

Applicable Quality Improvement Priorities

Over 75s Initiative Health Population Home First Service Tertiary Pathways Quality Measures Redesign of Out of

Hospital Services

Nurse Staffing Levels Flow Programme

Freedom of Information

Confidential (Y/N) (if yes, give reasons)

No

Final/draft format

Final

Ownership

Trust

Intended for release to the public

No

2

South Warwickshire NHS Foundation Trust

Report to Board of Directors – 5 October 2016

Board Assurance Framework and Quarterly Risk Report 1. Executive Opinion

This report provides an overview of our risk profile and approach to risk management as part of our cycle of quarterly assurance to the Board. Our approach to risk has evolved over the past few years and as a consequence we have been able to identify business and operational risks, implement mitigation strategies and have generally delivered well against our plans, contractual and statutory duties. This report does not highlight any particular concerns about our ability to continue to do so but does flag our highest current risks including the financial challenge faced by the Trust and by other organisations in the local health economy. 2. Board Assurance Framework (BAF)

The 2016-17 BAF Quarter 2 update is presented, 8-12 (Dark Amber) and 15-25 (Red) risks only, for approval, following review at Risk Management Board on 12 September 2016 (Appendix A). Principle risks have been identified by the Executive Team and cross referenced to the Trust Objectives (column 1) to which they are most pertinent. In addition the Trust Objectives have also been aligned to the Quality Improvement Priorities (QIP). This allows for a more focused approach. The risks are presented in order of current risk score. The Executive Lead for each risk has reviewed the controls and reported assurances, and updated the action plan as necessary. Following this the risk score was reassessed. The Director of Human Resources and Chief Technology Officer were of the opinion that currently there are no risks to the achievement of their objectives. This will be monitored on a quarterly basis. The Executive Lead for the following risk requests closure:

ID Risk Lead Risk 1075 Director of

Development Delay in the development of services due to a lack of an agreement process by STP resulting in a lack of public/service user and stakeholder engagement

The Executive Lead requests the addition of the following risk:

ID Risk Lead Risk 1080 Medical Director Progress in End of Life; Oncology; Children & Young

People is closely linked to the STP which may inhibit progress in producing appropriate solutions for South Warwickshire

1079 Director of Development

Causes of delayed programme are disputed between contractors and could incur costs for the Trust (Stratford Hospital)

3

The list below shows the change in risk score, all other risk scores have remained the same:

ID Risk Lead Increase / Decrease June 2016 September 2016 1071 Chief Executive Increase 4:4 (Dark Amber) 4:5 (Red) 1072 Chief Executive Increase 4:4 (Dark Amber) 4:5 (Red) 1073 Chief Executive Decrease 3:4 (Dark Amber) 2:4 (Dark Amber)

3. Organisational Risk Register

Risk Management Board met on 12 September 2016 and continues to meet quarterly. The Associate Directors of Operations (ADOs) for each Division and the Managing Director of the Out of Hospital Care Collaborative are required to attend the Risk Management Board meetings and submit a report highlighting any significant 8-12 (dark amber) and 15-25 (red) risks on their divisional risk registers. The Organisational Risk Register detailing risks scoring 15-25 (red) is attached for information (Appendix B). Complete copies of the 2016-17 BAF and Divisional Risk registers can be found on the Risk Management page of the Trust’s Intranet. Joanne Beales Lead Risk, Health and Safety Adviser

South Warwickshire NHS Foundation TrustBoard Assurance Framework (BAF) 2016-17

Appendix A - Objectives

Prepared: 12 May 2016 Collated by: Joanne Beales, Lead Risk, Health and Safety Adviser 1

Public and Patient Engagement

Domain Headline/Focus Objectives/Measures Executive Lead QIP

Quality Measures Achieve quality measures including patient/carer experience in maternity, dementia, falls and end of life pathways DN 1

Website Develop a website with a focus on health and wellbeing as part of a wider digital strategy DD

OoHS Continue to work with service users to design our out of hospital services DD 2

Well-beingIn collaboration with the third sector, agree a social prescribing programme of work beginning with the creation of a Well-being and Health Hub at Stratford Hospital

DD

Engagement Strategy Agree a membership and public engagement strategy DHR

Patient Outcomes Engage the population with principles of self-care; peer led Prevention, engaging local activism and patient outcomes DHR

(QIP) - 2016-17 Quality Improvement Priorities

Service Development

Objective Measure Executive Lead

Phase 1 Stratford Commission phase 1 of the new Stratford Hospital project DD

Phase 2 Stratford Develop plans for phase 2 DD

Business Plan Stratford

By June 2016, submit a business plan for the remaining accommodation space in the new Stratford Hospital build DD

Maternity Develop maternity services to meet the need of our local population Agree a business plan for the expansion of maternity services DD

Research Create an environment that encourages the application of technology Work with Universities and other organisations to develop our research capability in the use of technology CTO

Make well-being and health at the core of everything we do

Redesign our services to support delivery of out of hospital services

Improve engagement opportunities with our population

Prepare for the opening of the new Stratford Hospital and plan for the next phase




Partnerships

Objective Measure Executive Lead QIP

Partnerships - New Models of Care

Develop viable operating models with our local GP federation, initially with a focus on 'over 75s' CE 3

Engage Population Engage the population with principles of self-care and self-resilience including peer led Prevention MD 4

Home First Introduction of a Home First Service DOps 5

Care PathwaysEnhance our information integration capabilities to understand care pathways and resource interdepencies and requirements

DoF

Pathways Improve pathways and quality of tertiary services through close collaboration with UHCW and other neighbouring Trusts MD

6End of Life End of Life MDOncology Oncology MDC&YP Children and Young People MD


Workforce and Leadership

Objective Measure Executive Lead QIP

Nursing Levels Ensure safe nursing levels are achieved and sustained DN 7

Trust Benefits Continue to develop Trust benefits that support and incentivise the well-being and health of all our workforce DHR

Coach/Mentor Provide opportunities to coach and mentor staff in hard to recruit areas DHR

Wye ValleyEstablish a 'buddying' arrangement/relationship with Wye Valley NHS Trust to support peer improvement, learning and development

DOps

NHS Mgment Training Scheme

Create flexible management training posts and continue to be involved in the NHS Management Training Scheme DHR

Flow AcademyDevelop our flow and improvement capabilities through the establishment of a Flow Academy in collaboration with the Health Foundation

DD

Flow Programme Embed the flow programme learning principles throughout the organisation beginning with urgent care DOps 8

Perioperative Pathways

Increase the productivity of elective surgery through the development of leaner perioperative pathways MD


Adopt and embed lean processes across both in and out of hospital services

Strengthen out leadership capability by working with other systems and partner organisations to share best practice

Create a new model of care with primary providers and third sector organisations focused on out of hospital services

Implement integration of reablement and intermediate care

Work with our neighbouring providers to improve the quality of care pathways

Improve the well-being and health of our workforce




Sustainability

Objective Measure Executive Lead

Health Bid Continue to work with Health Bid to successfully tender for Out of Hospital Services and 0-5 years contracts DD

Procurement Strengthen internal capability to support and respond to major procurement exercises in line with Trust strategy DD

ICT Bids Prepare ICT bids to successfully access Sustainability and Transformation Funding CE

Non-NHS Income Continue to develop non-NHS income opportunities DoF

Adjusted Treatment Index

Agree a programme of work using the Adjusted Treatment Index and Service Line Reporting to understand efficiency savings opportunities across the Trust

DoF

Commissioned Activity

Create an information resource structure to support operational managers meet commissioned activity requirements

DoF

STPAgree a 5 year local health economy Sustainability and Transformation Plan

Deliver a compelling and credible 5 year local health economy Sustainability and Transformation Plan CE

Embed Service Line Reporting and Information Management within the organisation

Develop our commercial capabilities to maximise non-NHS opportunities to support core services

South Warwickshire NHS Foundation TrustBoard Assurance Framework 2016-17

Appendix A - QIP 2016-17


Quality Improvement Priorities (QIP) 2016-17

Public and Patient Engagement

1Achieve Quality measures for patient/carer in maternity, end of life, falls and dementia

2 Continue to work with service users to design out of hospital services

Partnerships

3Develop viable operating models with local GP Fed initial focus on over 75s

4Engage population in principles of self-care, resilience including peer led prevention

5 Introduction of home first

6Improve tertiary pathways through collaboration with UHCW and other Trusts

Workforce and Leadership7 Ensure safe staffing levels8 Embed the flow program principles beginning with urgent care


Appendix A - Abbreviations


BAF 2016-17 - Abbreviations

Board of Directors BoD Associate Director of Operations - Elective Care ADO - Elective Consultant Anaesthetist Cons Anae

Clinical Governance Committee CGC Associate Director of Operations - Emergency ADO - Emerg General Manager - Diagnostics GM - Diag

Finance & Performance Executive F&P Associate Director of Operations - Integrated & Community Care ADO - ICC Assurance Manager Ass Mgr

Management Board MB Associate Director of Operations - Support Services ADO - Support Service Improvement Manager SIM

Programme Delivery Board PDB Associate Director of Finance – Income & Contracts AD - Fin Scanning Bureau Manager SB Mgr

Council of Governors CoG Associate Director ICT Programmes AD - ICTP Transformation Programme Project Manager TPPM

Associate Director ICT Services AD - ICTS Nurse Consultant NC

Chief Executive CE Associate Director of Information & Performance AD - I&P

Chief Technology Officer CTO Associate Director of Programme Delivery AD - PD

Director of Development DD Associate Medical Director - Technology & Innovation AMD - T&I

Director of Finance DoF Deputy Director of Business Development & Transformation DDBD&T

Director of Human Resources DHR Head of Business Development HofBD

Director of Nursing DN Head of Community Nursing HoCN

Director of Operations DOps Head of Marketing & Communications HoM&C

Medical Director MD

Trust Secretary TS

South Warwickshire NHS Foundation Trust SWFT

Clinical Commissioning Group CCG

Trust Development Authority TDA

Warwickshire County Council WCC


Appendix A - BAF 2016-17

Prepared: 26/08/2016 Collated by: Joanne Beales, Lead Risk, Health and Safety Adviser 6

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Report to BoD BoD: 28/4/2016 Insufficient financial analysis of STP plans

STP governance process sets out timeline

STP 01/10/2016

Report to Board Workshop BoD Workshop: 25/05/2016

Detail of plan not shared with BoD

Awaiting approval from NHSE/NHSI CE 31/09/2016

Redesign of governance model through involvement of Price Waterhouse Coopers

Report to Business Performance and Investment Committee (BPIC) BPIC: 04/08/2016

CE agreement on Hospital reconfiguration

STP 1072

Plan does not gain approval due to resistance from public resulting in inadequate plan

CE 4 4 16 16 20 Support from NHSE and NHSI and politicians

National commitment to support transformational plans

BoD Workshop: 25/05/2016

4 5 20Public consultation document on major change proposals

Produce consultation document following STP sign-off

STP 01/10/2016

Terms of Reference for Interdivisional Board Interdivisional Board F&P Executive: 05/09/2016

Possible inappropriate solutions for South Warwickshire

Development of South Warwickshire solutions with OOHCC & GP Federation

MD - OOHCC Ongoing

Design Board (in the process of being established)

Engagement of District Council and other key stakeholders. "In principle" support secured

Lack of clear specification from Mechanical Engineering Consultants therefore unable to confirm final costs

Obtain clear specification from Mechanical Engineering Consultants

DD Ongoing

Business Case for Stratford Hospital agreed & approved.

BoD: 26/09/2012BoD: 27/02/2013

Insufficient contingency and initial project funds

Review options for provision for appropriate level of contingency

DD 30/09/2016

Clear project structure and reporting mechanism in placeApproved final contract sum based on phase 2 returns. BoD: 29/10/2014

Planning permission for enabling works received July 2014

Planning permission granted September 2014. Main contractor commenced on site

Stratford Project Board: 18/05/2015; 17/08/2016; 21/09/2016

Stratford Hospital multi storey car park opened on timeFund raising making good progressEnergy Centre Completed

Additional Project Management Capacity

Secretary of State provided legal endorsement of Section 106 requests

Restructure project to include work streams

Weekly design team meetings for early identification of issues

Capital Projects Update ReportMgment Board: 12/08/2016; 09/09/2016BoD: 05/10/2016

When

Initial Current CurrentSept 2016

Controls Assurances

Reported AssurancesIdentified in Board

reports and External Assessments

Gaps in Controls Gaps in Assurance Action Plan Who

4 16 16 20

STP governance arrangements in place and high level priorities agreed

STP 1071

Plan does not achieve sustainable solution by 2020/21 due to absence of radical solutions resulting in intervention from NHSE/NHSI

CE

Alig

ned

to O

bjec

tives

ID Risk Risk Lead

4 4 5 20

3 3 9

Stra

tford

Hos

pita

l

899

Project overruns in terms of cost and / or time due to lack adequate project governance structure resulting lack of capacity & delays implementation of next phase

DD 3 3 9 9 9

4 3 12

Pat

hway

s

1080

Progress in End of Life; Oncology; Children & Young People is closely linked to the STP which may inhibit progress in producing appropriate solutions for South Warwickshire

MD 4 4 16 12


Appendix A - BAF 2016-17


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Initial Current CurrentSept 2016

Controls Assurances



Gaps in Controls Gaps in Assurance Action Plan Who

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ID Risk Risk Lead

New electrical subcontractor appointed due to the original subcontractor going into administration

Better Care Fund Programme Integrated & Community Care Division F&P Report F&P: 03/05/2016

Access to home care packages restricts capacity of new service model

Capacity deficit to be highlighted to Better Care Fund Programme & SRG

DOps On-going

D2A Integration Project Board Integrated Performance & Quality Dashboard

BoD: 06/04/2016; 28/04/2016; 25/05/2016; 06/07/2016; 28/07/2016; 07/09/2016

Dashboard to identify unmet demand for Pathway 1 not in place

Develop Dashboard to identify unmet demand

MD - OOHCC 31/10/2016

Regular meetings with GP Federation (SWGP) leaders BoD: 25/05/2016 No formal proposal Make formal proposal to

SWGP CE 31/08/2016

Creation of new 'shadow' ACO divisional structure New Organisational Structure Agreed BoD: 27/07/2016

SWGP representatives to new structure not agreed

Need to agree SWGP representatives to new structure

CE 31/08/2016

Create new design group for Out of Hospital STP work stream Board workshop BoD Workshop:

27/07/2016Options paper on legal forms Produce Paper TS 01/11/2016

Stratford Project Board Risk Log Stratford Project Board: 17/08/2016; 21/09/2016

Lack of understanding of the reasons for delays with the project

Quantity Surveyor to undertake a Review & Analysis

DD 30/09/2016

Regular meetings with the main contractor

Updated programme to begin September 2016

Better Care Fund Programme Integrated Performance & Quality Dashboard BoD: 02/12/2015 Section 75 not in place

for Integrated ServiceBoard & WCC to approve Section 75s DOps 31/10/2016

Section 75 agreed for D2A pathway 3 beds

Principle case for change agreed at SWFT BoD & WCC Cabinet BoD: 28/01/2016

D2A Integration Project Board Integrated Performance & Quality Dashboard

BoD: 06/04/2016; 28/04/2016; 25/05/2016; 06/07/2016; 28/07/2016; 07/09/2016

Agreed strategy of integration of existing systems

Need to feedback views from GP engagement workshop into ICT plan

Briefing paper to BoD CTO 31/08/2016

Revised Trust capital allocation Need worked-up IT integration plan

Produce IT system integration plan CTO 31/10/2016

Car

e P

athw

ays

1076

Lack of information re: capacity available in reablement due to a lack of information from partners leading to inadequate flow and more expensive in-patient provision

DoF 2 4 8 8 8 D2A Integration Project Board Integrated Performance & Quality Dashboard

BoD: 06/04/2016; 28/04/2016; 25/05/2016; 06/07/2016; 28/07/2016; 07/09/2016

2 4 8Dashboard to identify unmet demand for Pathway 1 not in place

Develop Dashboard to identify unmet demand

MD - OOHCC 31/10/2016

1074

Model not agreed by the GP Federation due to lack of transformational content resulting in alternative new model of care

ICT

Bid

s

1073

External funding not available to support ICT due to national financial re-set resulting in lack of progress on integration

CE 3 4 12 12 8 2 4 8

Hom

e Fi

rst

997

9

Par

tner

ship

s - N

ew

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els

of C

are

4 2

CE 3 3 9 9 9

3 3

3 3

Hom

e Fi

rst

993

Integration of CERT & reablement doesn't release sufficient increase in capacity to meet daily demand leading to discharge delays

DOps 3 3 9 9 9

8

Failure to agree a Section 75 agreement to provide Governance and Partnership working delays the benefits of delivering an integrated service

DOps 4 2

3 3 9

8 8 8

9

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tford

Hos

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1079

Causes of delayed programme are disputed between contractors and could incur costs for the Trust

DD 3 3 9 9


Appendix A - Closed


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Actively involved in the STP process STP Update BP & I Comm: 13/06/2016

National Plans by June 2016

Successfully established a process in South Warwickshire which could be replicated throughout Warwickshire

CurrentA

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ID Risk Risk Lead

Initial

Controls Assurances



Current

Gaps in Controls Action Plan Who WhenGaps in Assurance

RMB 12/09/2016 Suggest Closure due to a clear process being agreed

OoH

S

1075

Delay in the development of services due to a lack of an agreement process by STP resulting in a lack of public/service user and stakeholder engagement

DD 3 3 9 9

South Warwickshire NHS Foundation Trust15-25 (Red) Risk Register

Appendix B

Prepared 13/09/2016 Collated by: Risk, Health and Safety Team 20

Q1 Q2 Q3 Q4

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015 1038 Non achievement of Trust

Cost Improvement Plan (CIP) targets 2016/17 because of non-delivery of schemes which could affect the Trusts ability to achieve planned financial surplus and hence the affordability of new developments

22/09/201603/12/2015- Risk added onto risk register ,Agreed by EmergencyRHSG.17/12/2015 (EmergencyRHSG) - Plans worked up not yet agreed. Risk remains the same.28/01/2016 (EmergencyRHSG) - Shortfall of £500k - £1m. Risk remains the same.25/02/2016 (EmergencyRHSG) - Meeting arranged to discuss on 29/02/16.Risk remains the same.24/03/2016 (EmergencyRHSG) - CIP £900k identified, to be discussed at Confirm and Challenge meeting with Board of Directors 06/04/2016. CCG contract 2016/17 to be agreed. Risk score remains the same.

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) 16 1. With Finance, divisional management team review 3rd Thursday of month the budget position and CIP delivery 2. Monitor e-rostering against ward / directorate budgets –use unused shifts before applying for bank staff3. Challenge all requests for agency staffing – medical and nursing4. ADO is meeting with directorate CD/ GM/ Finance bi-monthly to discuss performance, budgetary position and CIP delivery against directorate5. Awaiting identification of Income allocation to areas with live PbR – A&E, Cardiology and Diagnostics6. Work across divisions to improve performance / reallocate responsibilities to mitigate need for

a. Locum bookings (medical staff appointed

1. GM / ADO / Finance2. GM / ADO / Finance3. HR / ADO4. ADO5. Income / Finance6. ADO’s / HR / AMD7. ADO8. GM / ADO / AMD / HR9. ADO / Finance

16 16 1. Submission of CIP proposals 2. Hidden CIP’s not recognised delivered through bed days saved (ADMISSION AVOIDANCE)3. Risk remains high against delivery of many plans4. Finance to attend weekly Emergency Division team meetings5. Monthly GM / Matron and Ward Manager meetings for all clinical areas to report CIP position and progress6. Report CIP delivery and proposals through Emergency Divisional reporting to Emergency board on a monthly basis7. CIP planning for 16/17 already underway

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Controls/Actions required Responsibility Completion

Date

On-going till delivery

Review date

RISK REGISTER 2016-17 Open Risks with a Current Score of 15-25 (not included on BAF)

Controls in place Monitoring Group Notes

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ID Description Supplementary information


Appendix B


28/04/2016 (EmergencyRHSG) - CIP £1.3m outstanding with the £900k accepted at Board. Ambulatory Care negotiations on going. Risk remains the same.26/05/2016 (EmergencyRHSG) - CCG not agreed Ambulatory Care fee. Risk remains the same.07/07/2016 (EmergencyRHSG) - Further CIP schemes have been put forward. Risk to remain the same.04/08/2016 (EmergencyRHSG) - A quarter of the CIP has been identified non-recurrently. The capacity to close the gap remains a risk. Risk remains the same.25/08/2016 (EmergencyRHSG) - A further £100k submitted for approval. Continuing to identify CIPs. Risk remains the same.

( pp for 12months to monitor annual leave/sickness/study leave)b. Move to all disciplines utilising e-roster – diagnostics remain outstanding areas c. Enhance Sickness management of both medical and nursing teamsd. Reduce LOS to mitigate risk of needing additional capacity through winter 15/16 – identify method to count improvements against CIP submission7. Quarterly divisional workshop will be used post-Christmas to report CIP plans and financial position for improved engagement, leadership and performance across directorates8. Budget management and delivery of CIP will form part of objectives through IPR process for GM/ Possibly CD9. Monitoring areas of under-spend with review for identification of potential non-recurrent savings10. Review theatre and outpatient activity to identify areas for improved productivity and therefore, potential income11. Review and monitor all stock levels – implement stock control systems12. Explore new ways of working to release efficiencies in pathway management eg: ambulatory care


Appendix B


1-9. SMT within the Division

1-9. On-going till delivery

06/10/2016

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6 1083 Non achievement of Trust Cost Improvement Plan (CIP) targets 2016/17 because of non-delivery of schemes which could affect the Trusts ability to achieve planned financial surplus and hence the affordability of new developments.

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of O

pera

tions 08/09/2016 - Added to

the risk register agreed by WCRHSG

Maj

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) 1. Monitor e-rostering against ward / directorate budgets –use unused shifts before applying for bank staff2. Challenge all requests for agency staffing – medical and nursing3. ADO is meeting with directorate CD/ GM/ Finance bi-monthly to discuss performance, budgetary position and CIP delivery against directorate4. Work across divisions to improve performance / reallocate responsibilities to mitigate need for a. Locum bookings (medical staff appointed for 12months to monitor annual leave/sickness/study leave)b. Move to all disciplines utilising e-roster – diagnostics remain outstanding areas c. Enhance Sickness management of both medical and nursing teams5. Future Divisional workshop will be used to report CIP plans and financial position for improved engagement, leadership and performance6. Budget management and delivery of CIP will form part of objectives through IPR process for GMs and Heads of departments7. Continue planned work with other Divisions to assist delivery of CIP schemes agreed predevelopment of Women and Children’s Division8. Monitoring areas of under-spend with review for identification of potential non-recurrent savings9. Deliver workshops to ward/area managers on procurement processes and good practice.

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Women's & Children


Appendix B


1-3. Capital and Estates Committee

1-3. 31/03/2017 11/10/2016

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(3) 15 15

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2014 921 Failure of the single high

voltage (HV) supply cable to the main site due to the obsolete high voltage switchgear and or the inability to connect temporary generators to the electrical system in the event of a loss of supply resulting in loss of clinical services.

The existing generator is insufficient in capacity to supply backup power to the Support Services side of Lakin Road site in the event of loss. The Department of Health document “A risk-based methodology for establishing and managing backlog” recommends that power centres have a useful life of 25-35 years. The plant in Lakin Rd substation is over 40 years old and has now become obsolete.

13/01/2015 (SSAOGG) - Installation of disaster plan in progress. Risk remains the same.10/02/2015 (SSAOGG) - Bid made to Capital & Estates Committee, result expected in March 2015. Risk remains the same.10/03/2015 (SSAOGG) - Head of Estates to review risk score.14/04/2015 (SSAOGG) - Risk remains the same.12/05/2015 (SSAOGG) - Risk remains the same.09/06/2015 (SSAOGG) - Risk remains the same.14/07/2015 (SSAOGG) - Risk remains the same.11/08/2015 (SSAOGG) - Risk remains the same.08/09/2015 (SSAOGG) - Request for funding to be made from 2016-17 budgets. Risk remains the same.13/10/2015 (SSAOGG) - Risk remains the same.10/11/2015 (SSAOGG) - Risk remains the same.08/12/2015 (SSAOGG) - Awaiting considerable investment in Capital funding.Risk remains the same.12/01/2015 (SSAOGG) - Project is on the Capital programme 2016-17.Risk remains the same.09/02/2016(SSAOGG) - On going issue, to be tabled in meeting next week. Risk remains the same.08/03/2016 (SSAOGG) - Tenders for generator came in over budget, capital

Cat

astr

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c (5

)

Poss

ible

(3) 15 1. Replacement of HV

switchgear in 4 HV substations (Lakin Rd, Green Lane, Wathen Rd and Millers Rd)2. Install a cable to convert the HV radial supply into a ring main.3. Installation of disaster plan connection points to both generators in the Green Lane substation.

15 1. Monthly generator testing

Support Services


Appendix B


over budget, capital project for 2016/17. Risk remains the same12/04/2016 (SSAOGG) - On Capital & Estates programme 2016-17 unfunded but allocated high priority. Risk remains the same.10/05/2016 (SSAOGG) - Working Group developed to consider prioritisation of £500k. Risk remains the same.14/06/2016 (SSAOGG) - Prioritisation of works to be reconsidered. Risk remains the same.12/07/2016 (SSAOGG) - Full scope of works being undertaken. Tender process commenced. Risk remains the same.08/08/2016 (SSAOGG) - Risk remains the same.13/09/2016 (SSAOGG) - Costs being worked up scheme will either be funded in 16/17 or 17/18. Risk remains the same.


Appendix B


Infra

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10 J

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2014 922 Failure of power supply

(Support Services side of Lakin Road site) due to insufficient capacity of the backup generator resulting in loss of clinical services

The existing generator is insufficient in capacity to supply backup power to the Support Services side of Lakin Road site in the event of loss. The Department of Health document “A risk-based methodology for establishing and managing backlog” recommends that power centres have a useful life of 25-35 years. The plant in Lakin Rd substation is over 40 years old and has now become obsolete.

13/01/2015 (SSAOGG) - Risk remains the same.10/02/2015 (SSAOGG) - Bid made to Capital & Estates Committee, result expected in March 2015. Risk remains the same.10/03/2015 (SSAOGG) - Head of Estates to review the risk score.14/04/2015 (SSAOGG) - Risk remains the same.12/05/2015 (SSAOGG) - Pathology workload due to increase, therefore more services will be affected by loss of power. To be raised at the next Capital Funding meeting. Risk remains the same.09/06/2015 (SSAOGG) - No funding via Capital, to consider EMC budget. Risk remains the same.14/07/2015 (SSAOGG) - £300k funding approved. Will need to go through the tendering process 10-12 week timescale.11/08/2015 (SSAOGG) - Working on specification for tendering process to be implemented, to be purchased 15/16. Risk remains the same.08/09/2015 (SSAOGG) - Tendering process to be completed by 31/12/2015. Generator installation to be completed by 31/03/2016. Risk remains the same.13/10/2015 (SSAOGG) - Risk remains the same.10/11/2015 (SSAOGG) - Risk

1-3. 31/03/2017 11/10/20161. Reduction of staff working on site2. Local low voltage switching

15 Support Services

Cat

astr

ophi

c (5

)

Poss

ible

(3) 15 1. Replacement of the

transformer and associated switchgear within the Lakin Rd substation.2. Replacement of the generator sized to carry the whole load.3. Ensure authorised person’s training is maintained.

1-3. Capital & Estates Committee

15 15

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Appendix B


(SSAOGG) Risk remains the same.08/12/2015 (SSAOGG) - Awaiting Capital funding.Risk remains the same.12/01/2016 (SSAOGG) - Tendering process for generators commenced.To be intsalled by 31/3/2016.Risk remains the same.09/02/2016 (SSAOGG) - On going, to be tabled in meeting next week. Risk remains the same.08/03/2016 (SSAOGG) - Funding from capital & essential maintenance budgets in 2016/17. Risk remains the same.12/04/2016 (SSAOGG) - Funding allocated over budget estimate, back out to tender. Risk remains the same.10/05/2016 (SSAOGG) - Allocation increased for the Tender. Tender to close 30/06/2016. Risk remains the same.14/06/2016 (SSAOGG) - Prioritisation of works to be reconsidered. Risk remains the same.12/07/2016 (SSAOGG) - Tender process for the generator has closed. Prioritisation of works to be considered. Risk remains the same.08/08/2016 (SSAOGG) - Risk remains the same.13/09/2016 (SSAOGG) - Costs being worked up scheme will either be funded in 16/17 or 17/18. Risk remains the same.


Appendix B


1. Ongoing 29/09/201615 1. Proactive recruitment project2. Recruitment and Retention Group reviewing vacancies/recruitment hot spots3. Revised Sickness Absence Management Policy4. Internal locum bank for medics5. Shadow rota for medical staff6. No weekend working in Ophthalmology wef 01/08/2015

Elective

Mod

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)

20 J

uly

2015 1012 20/07/2015 - Added to

risk register, agreed by ElectiveRHSG17/08/2015 (ElectiveRHSG) - GMs to provide up to date information re: temporary labour usage. Risk remains the same.28/09/2015 (ElectiveRHSG) - Temporary labour costs re reducing across the Division. Budget figures due w/b 05/10/2015, potential for risk score to be reduced. Risk remains the same.12/11/2015 (ElectiveRHSG) - Risk remains the same.17/12/2015 (ElectiveRHSG) - Risk remains the same.25/01/2016 (ElectiveRHSG) - Risk remains the same.29/02/2016 (ElectiveRHSG) - Risk remains the same.31/03/2016 (ElectiveRHSG) - No increase in budget for 2016/17. Risk remains the same.28/04/2016 (ElectiveRHSG) - Improved slightly. Consultant interviews in May 2016. Risk remains the same.26/05/2016 (ElectiveRHSG) - Review of Divisional Temporary Labour Costs completed, no change expected until August 2016. Risk remains the same.30/06/2016 (ElectiveRHSG) - Plan in place for removing locums. Risk remains the same.28/07/2016 (ElectiveRHSG) - No update from Risk

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) 15 15 15 1. Implementation of Staff Flow for medical agency

1. ADOTemporary labour costs continue to be high due to the volume of temporary

labour and costs leading to an overspend on divisional

budgets

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15 1. Purchase a Unisoft scheduling system2. Embed updated standardised Unisoft / Evolve user process / practice by clinical team. Post implementation of Unisoft Scheduling.3. Embed updated standardised booking process by the Administrative team using Ormis / Lorenzo / Unisoft / Evolve. Post implementation of Unisoft Scheduling.4. Minimise system transfer workarounds and implement a Unisoft scheduling system with appropriate Lorenzo / Evolve two way interfaces 5. To undertake a full review of the booking teams roles, line management and responsibilities

1-5. Endoscopy Coordinator, Mobilisation Programme Manager, Endoscopy Lead Practitioner, Endoscopy Sister, GM – Critical Care, Consultant

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(3) 12 15 15 1. Undertake full look back

exercise for all Endoscopy patients between April 2015 / April 2010 2. Establish standardised Unisoft / Evolve user process / practice by clinical team.3. Establish standardised booking process by the Administrative team using Ormis / Lorenzo / Unisoft / Evolve 4. Establish robust daily data tracking system for all patients undergoing a procedure in Endoscopy.5. Revise Evolve booking form.

Elective

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26/05/2016 - Risk added to the risk register, agreed by ElectiveRHSG.30/06/2016 (ElectiveRHSG) - Look back exercise has examined 1770 patients, 43 patients have been missed, but not over their review timescale. 3 patients over review timescale harm apparent. Risk score increased to 5:3.28/07/2016 (ElectiveRHSG) - Validation work on going. Risk remains the same.25/08/2016 (ElectiveRHSG) - CGC assured of the process for look back exercise (Aug 2016). Fellows & Ex-Consultants being recruited to undertake the look back exercise. Monthly reporting to Elective AOGG & CGC. Risk remains the same.

Clin

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Inci

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repo

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26 M

ay 2

016 1063 Potential failures to book

follow up procedures for Endoscopy patients due to a process failure resulting in delayed diagnosis of patients.

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update from Risk Owner. Risk to be reviewed August 2016.25/08/2016 (ElectiveRHSG) - Current overspend £500k. Forecasting in place. Risk remains the same.

1-5. 6-12 months 29/09/2016


Appendix B


15 1. Review bed numbers and potential to close 6 beds to improve staffing ratio.2. Review nurse placements on Beaumont Ward with the potential to redeploy 1 nurse3. Recruitment of band 6 to improve skill mix and senior support being reviewed (dependent on the closure of beds)4. Support of practice development to work planned hours agreed in advance with the ward manager with current international nurses and newly qualified that have been recruited once started.5. Liaison with recruitment to prioritise band 2 vacancies.6. Development of Ward specific competencies for Part 2 of the preceptorship to ensure all staff has a projected pathway of development and the ward can plan against skills available in a predicable manner.7. Advance bank requests and an early escalation to agency if needed to promote block booking.8. Ward clerk supporting with completing Safecare and putting on ward attenders. Ward staff to do at weekends.

1. ADO’s; GM’s2. Ward Manager; GM3. Ward Manager; GM4. Practice Development5. Ward Manager & Matron6. Ward Manager; Practice Development7. Ward Manager; GM8. Ward Manager

1. 30/09/20162. 30/09/20163. 31/10/20164. 31/01/20175. 31/08/20166. 30/11/20167. Review weekly8. Review data for completeness and accuracy Sept 2016

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) 15Insufficient senior staff to mentor and preceptor staff potentially leading to poor staff retention and development and errors due to lack of supervision. This is due to a low combined collective length of service and experience in the area.Risk of poor patient experience due to insufficient staff with the right competencies to care for their specific needs every shift .e.g. Management of early pregnancy lossExample: there are been 2 recent incidents of failure to escalate a deteriorating patient due related to staff inexperience or use of temporary staffing. There has been an incident relating to early pregnancy loss where a patient received poor advice and suboptimal care.Vacancy Factor: 8.33 band 5s in post against ASL of 14.34In addition, contributory factors:Maternity leave x 2 due to return in Sept part time 1.11 combined with sickness gave band 5 non availability of 24% for July.1 Band 5 no pin pending NMC decision- Hearing decision Sept at the earliest, currently working as band 2.1 Band 6 vacancy out to advert4.3 band 2 vacancies – vacancies at band 2 since Feb 2016 – only one post filled part time in June 2016.Safecare: Not currently appearing to reflect staff utilisation as did not consistently capture nurse care hours on telephone consultations or ward attenders.ASL and staff planning for 11 beds: Currently

Clin

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08 S

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r 201

6 1084 Vacancies combined with suboptimal skill mix (high proportion of junior to senior staff) due to poor staff retention resulting in additional workload for existing staff, potential increase in sickness/staff attrition due to staff fatigue and potential patient harm.

Mod

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)

Alm

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in (5

)1. Practice development spending time on ward.2. Matron visiting the ward regularly3. Off duty reviewed regularly and shifts put out to bank and agency4. Proactive management of sickness/absence with staff on targets/appropriate stage of Policy5. Central recruitment holding band 2 days.6. Management of annual and carers leave7. Roster review with GM, including full review of all flexible working patterns/ working restrictions in place with HR to facilitate safe and fair rostering

Women's & Children

08/09/2016 Added to the risk register agreed by WCRHSG

15 06/10/2016


Appendix B


for 11 beds: Currently open to 17 beds with a variety of specialities. This requires staff to have skills across medicine and surgery. It impacts on the ward’s identity as Gynaecology and the recruitment of staff that have an interest in this.Communication/Competency issues of some staff – Impact on care delivery to Beaumont GAU patients due to requirement for extended period of supernumerary status as needing additional support with language skills.

Maj

or (4

)

Like

ly (4

) 16 Long Term:1. Building redesign and extension to include new plant (existing washers will be obsolete in 18 months’ time, due to regulation changes)

2. Capital Team 1. 30/09/201616 Air Handling Plant:1. 6 monthly ppm

Generators:1. Service contract in place with external provider quarterly ppm. 6 hour response time for breakdowns

Washers:1. Pipe work leading to AER sanitised and replaced.2. Water tank above Endoscopy unit sanitised.3. 3 stage filter bank fitted by Estates and changed regularly.4. Small filter 0.2 micron fitted to machine.5. A comprehensive test on type of mycobacterium has been conducted to determine type or bacterium. Respiratory team been informed and risk assessing patient groups.6. Weekly water sampling continuously done and no micro-organisms (TVC) found in recent test.

Other:1. Staff members working extended hours to maintain decontamination processes to meet service requirements.

Elective 19/01/2015 (ElectiveRHSG) - Business Case to be submitted by March 2015. Review March 2015. Risk remains the same.23/03/2015 (ElectiveRHSG) - Meeting cancelled due to other pressures of work.20/04/2015 (ElectiveRHSG) - Business case ongoing. Expected start date 6 months.28/09/2015 (ElectiveRHSG) - Risk being managed by the Capital Team, with a risk log which contains the technical options available. Elective Care Division are unable to take any further actions to reduce the risk. Risk remains the same.17/12/2015 (ElectiveRHSG) - Awaiting Capital Project implementation and completion. Elective Care Division cannot take further actions. Risk accepted.

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) 16 16

Perfo

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Haz

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15 D

ecem

ber 2

014 949 Service disruption due to

obsolete equipment (air handling plant, generators, washers) resulting in a compromised Endoscopy Service.

The decontamination equipment is ageing and becoming increasingly difficult to source parts for repair or replacement.

RISK REGISTER 2016-17 Accepted Risks

29/09/2016


Appendix B


RISK REGISTER 2016-17 Risks Closed during Quarter 1: April - June 2016

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