5.4 trust risk register · 2017-01-25 · the trust risk register report provides assurance that...

Paper 8.0

Trust Board26th January 2017

AGENDA ITEMNUMBER

5.4

TITLE OF PAPER Trust Risk Register

Confidential YES

Suitable for publicaccess

YES

PLEASE DETAIL BELOW THE OTHER SUB-COMMITTEE(S), MEETINGS THIS PAPER HAS BEENVIEWED

Quality and Performance Committee

STRATEGIC OBJECTIVE(S):

Best outcomes √ Identify risks to patient safety and acing upon them is inherent in achieving best outcomes for patients.

Excellent experience √ Proactive management of risks enhances patient experience.

Skilled & motivatedteams

√ Safety is improved when teams are proactive in the management of risks to patient safety.

Top productivity √ Productivity is improved when patient safety risks are managed effectively and risks are avoided.

EXECUTIVE SUMMARY

This report summarises the Trust Risk Register as at 19/01/2017. There arecurrently 6 risks on the Trust Risk Register. Three risks have beendowngraded and one has been closed.

The Trust Risk Register report provides assurance that relevant risks havebeen identified as Trust risks and that mitigating actions are in place.

The Risk Register links to all Strategic Objectives.

RECOMMENDATION: For Assurance

SPECIFIC ISSUES CHECKLIST:

Quality and Safety

Patient Impact

Employee

Other Stakeholder

Equality & Diversity

Finance

Paper 8.0

Legal The Trust Risk Register is required by the Department of Health and is afundamental operating requirement of Monitor.

Link to Board AssuranceFramework PrincipleRisk

AUTHOR NAME/ROLE Michael Imrie, Deputy Medical Director/Chief of Patient Safety

PRESENTED BYDIRECTORNAME/ROLE

Michael Imrie, Deputy Medical Director/Chief of Patient Safety

DATE 20/012016

BOARD ACTION Review the paper and approve changes.

Paper 8.0

of 16

ID Title DescriptionRiskOpened

Risk LevelCurrent

Risk LevelTarget

Action Plan ProgressReviewDate Monitoring

1368 Patients lost tofollow up inUrology leading torisk of advanceddisease state

Urology cancer patients nottracked and lost to follow upappointments andtreatment. Potential delayand risk of patientspresenting with advanceddisease state.

CATASTR

20

16/072014

CATASTR

16

NEG

2

Apr 2015:1) For PSA patients for IT toidentify duplicate hospitalnumbers to determine exactnumber of patients.2) Check the number ofpatients in the system whohave not had anappointment in the last year.3) Remaining patients tohave review of last letterwritten.4) Consultant Urologist tolead eview of action plan

meeting.

Jan 2015: SIRI Action planto be approved by CCG inJan 15. Local Action Planalready in progress.

Sept 2014: Admin review ofnotes (circa 700 to ascertainextent of problem. Ownfollow up process to belooked at and implemented.Those found to be lost tofollow up to be reported as aSIRI and investigated fully.

Dec 2016: Risk to be reviewed and incorporated into awider Trust risk regarding loss to follow up.

Nov 2016: Awaiting Trust patient tracker system.

October 2016: Urology patient capacity has improved.Bespoke patient tracker system is currently indevelopment for Cancer Services. If this tool issuccessful then it can be rolled out to specialties totrack patients.

August 2016: Departmental meeting with CancerSupport NHS Improvement to discuss/provide supportwith Urology cancer pathways.

July 2016: Meeting with Cancer Support NHSImprovement 28/7/2016 to discuss urological cancerpathways – to assist with efficiency, quality andpatient/staff safety for patients on cancer pathway.

June 2016: Focused effort by admin staff to clearoutpatients follow up waiting list. Extra consultantclinics held. Registrar also holds weekly outpatientclinics to assist with this process. RDC still embeddingbut feedback from Cancer Services is that the wait forflexicystoscopy (a key diagnostic) has been improved.

May 2016: Consultant led Rapid Diagnostic Clinics(RDC) have commenced enabling TWR patients onbladder cancer pathway to receive diagnosis withinpathway time span and start treatment forthwith.RDC also facilitating rapid diagnostics to patientssuspected of prostate/renal cancer.CNS support present in all RDC’s.RDC currently under audit.RDC’s improving communication between urologyteam and patients; expediting diagnosis,commencement of treatment and overall patient

09/12/2016 ExecLead:LorraineKnight

LeadManager: TerriHess

Paper 8.0

of 16


Risk LevelCurrent

Risk LevelTarget


1451 Clinicians may beUnsighted to, orFail to Review, theResults of PatientInvestigations

(CQC outcome 21 & 16)There is a risk that cliniciansmay be unsighted to, or fail toreview, the results of patientinvestigations and that clinicalcare may be compromised asa result. There is a lack ofconsistent, robust processesto ensure that clinicians areaware of the results of clinicalinvestigations and takeappropriate actions as aresult. This risk replaces1412.

MAJOR

15

24/06/2015

MAJOR

15

NEG

2

Jun 2015:1) Trust to considerdeployment of anOrdercomms system whichwould enable Clinicians totrack outstandinginvestigations.

2) Review of current clinicalsystems to identify bestpractice.

Dec 2016: Implementation Q4 16/17. Furthermodalities to follow.

September 2016: Awaiting progression ofimplementation of Ordercomms projected December2016.

May 2016: A business case for an Ordercommssystem in currently in development.

March 2016: EMR roll out to commence in May 2016with completion planned for November 2016.

Jan 2016: Ordercomms system available from SPS.Implementation currently planned to follow EMR rollout.

Jun 2015: New Risk – this replaces risk 1412 - Risk offailure to act on abnormal Pathology results – closed24/06/2015

13/01/2017 Exec Lead:MedicalDirector

LeadManager:Mick Imrie

Paper 8.0

of 16


Risk LevelCurrent

Risk LevelTarget


1498 MandatoryMedicinesManagementTraining

There is an organisationaldevelopment risk of poormedicines managementpractice due to lowcompletion of mandatorymedicines managementtraining. There wasfeedback from CQC (2015)on low adherence inpaediatrics. Trustwideadherence in May 2016 is77%. The target is 90%.

MAJOR

15

13/6/16

MAJOR

15

NEG

1

Nov 2016: Assistant DivisionalDirectors, Divisional Chief Nursesand Divisional Directors are informedof the inadequate rates of training.

June 2016: Divisional managers havebeen sent the figures and asked toaction improvements.

Dec 2016:MES: May 75%; June 68%; Aug 68%;Sep 63%; Nov 57%Quality Medical Nursing & Midwifery:May 42%; June 38%; Aug 50%; Sept44%; Nov 44%TASCC:May 82%; June 75%; Aug 78%; Sep76%; Nov 64%DTTO:May 71%; June 73%; Aug 54%; Sep78%; Nov 78%WH&P:May 78%; June 78%; Aug 80%; Sep77%; Nov 78%WOD:May 63%; June 64%; Aug 82%; Sep78%; Nov 54%

Nov 2016:MES:May 75% June 68% Aug 68% Sept 63%Quality Medical Nursing & Midwifery:May 42% June 38% Aug 50% Sept 44%TASCC:May 82% June 75% Aug 78% Sept 76%DTTO:May 71% June 73% Aug 54% Sept 78%WH&P:May 78% June 78% Aug 80% Sept 77%WOD:May 63% June 64% Aug 82% Sept 78%

Sept 2016: The Trust position remains

22/01/2017 Exec Lead:LouiseMcKenzie

LeadManager:PrashantSanghani

Paper 8.0

of 16

unchanged.

July 2016: There has been a worseningof the position:MES – May 16: 75%, June 16: 68%.Quality Medical Nursing & Midwifery –May 15: 42%, June 16: 38%.TASCC – May 16: 82%, June 16: 75%T&O – May 16: 71%, June 16: 73%WH&P – May 16: 78%, June 16: 78%WOD – May 16: 63%, June 16: 64%Overall Total – May 16: 77%, June 16:72%


RiskLevelCurrent

RiskLevelTarget


1429 Shortage of staffon Swan Ward

Despite recruitment there arecurrently 3 nursing vacancieson Swan Ward. There arehigh levels of sickness andagency use. Staff are alsobeing taken to supportescalation areas such asSwift Ward. Additionally onestaff member is due to go onmaternity leave in March.This also affects the ability torelease members of staff toundertake necessary training.Impact is on quality of patientcare and safety - e.g.increased incidents includinghospital acquired pressureulcers. Also decreased staffsatisfaction and stressleading higher sicknessrates.

MODER MAJOR

15

MINOR Feb 2015: Some vacancies havealready been recruited to - 1 newstarter on 8/1/15, 2 nurses fromoverseas are due to start in March.Arecruitment day is planned for24/01/2014

Nov 16: Ward Manager has resigned andis due to leave at end of Dec - job currentlyout to advert. There are more nurses dueto start maternity leave in the comingmonths, although some have recentlyreturned there will a higher total number offon maternity leave (up to 7). DCN hasbeen working on a plan to mitigate againstthe Ward Manager vacancy and matLeave.

Sept 16: CPE back from mat leave, newband 6 appointed. Still 3 staff on mat leaveand 2 more due to go in Dec. 2 RNvacancies. HCA's have recently beenrecruited. Still heavy bank/agency use andsickness. Work ongoing to fill vacancies

Apr 16: proactively still trying to recruit,manage sickness and cover shifts. Riskremains unchanged.

12/01/17 Lead Manager:Cathy Parsons,Kelly Irvine,Yvonne Jones

Paper 8.0

of 16


Risk LevelCurrent

RiskLevelTarget


1525 Joint Trust CCGQIPP Delivery

There is a risk that the JointTrust/CCG QIPP schemesare not delivered, leading tocontinued activity pressures,the crowding out of electiveactivity and hence significantloss of margin, costpressures and bottom linefinancial impact. Alsoadditional financial riskthrough the application of therisk sharing mechanism.

CATASTR

16

22/09/2016

CATASTR

16

MINOR Sept 16: Continue regular jointdelivery meetings with CCG;Regular meetings with CCG Directorof Finance and Joint Delivery Director;and Monitor QIPP delivery schedules.All responsibility of Director of Finance

and Information – monthly reviews

Dec 16: The position remains similar in thatthe CCG are likely to have to bereimbursed under the risk sharingagreement as forecast QIPP deliveryremains below £4m.

Nov 16: The existing schemeimplementation plan continues to be rolledout with new schemes also beinggenerated. However, the impact of thesein 16/17 remains substantially below the£4m risk sharing amount and hence someform of payment back to the CCG is likely

to be required.

Sept 16: New risk

30/01/2017 Exec Lead:Simon Marshall

Lead Manager:Paul Doyle


Risk LevelCurrent

RiskLevelTarget


1526 Requirement foradditional CIP’s

There is a risk of the Trust

not having the ability to

control costs within our

existing budgets and

reserves to prevent the CIP

asking increasing / planned

surplus reducing.

CATASTR

16

22/09/2016

CATASTR

16

MINOR Sept 16: Review by ExecutiveDirectors of current cost pressures -09/09/16.Finance recovery plan meetings withDivisions - 16/09/16.Mitigate additional cost pressures viaadditional savings - Ongoing.Monthly reporting to Execs of financialpressures - Monthly.

Dec 16: Divisions identified a fewadditional CIPs in November and theforecast gap has been reduced to £0.5m(last month was £0.6m)..

Nov 16: Divisions identified a fewadditional CIPs in September and theforecast gap has been reduced to £0.6m(last month was £0.7m).

Sept 16: New risk


Lead Manager:Des Irving-Brown

Paper 8.0

of 16

Paper 8.0

of 16

Risks Downgraded


Risk LevelCurrent

RiskLevelTarget


1524 iMSK There is a risk that the iMSK

clinical teams do not amend

their clinical practice /

behaviours and hence the

required savings only prove

partly deliverable. Total risk

FYE £3.9m however we

believe about 50% of this has

already been mitigated via

the interim model and further

actions are in hand.

CATASTR

16

22/09/2016

MOD

12

MINOR Sept 16: iMSK steering group and

project sub groups. iMSK

implementation plan, risk register,

project controls. iMSK contract

monitoring group to be established

with CCG from 1st October 2016.

Further mitigating actions will be

required across the first 18 months of

the contract as required.

Nov 16: No changes, implementation planis progressing to timeline.

Sept 16: New risk


Lead Manager:Paul Doyle

Paper 8.0

of 16


Risk LevelCurrent

Risk LevelTarget


1244 StaffSatisfaction

There is a risk that staffsatisfaction declines therebyadversely affecting shortterm performance and longterm goals.

CATASTR

16

26/06/14

MODER

12

MODER

8

March 2016: National StaffSurvey highlights continuedchallenges aroundperceived support fromimmediate managers andconfidence raisingconcerns. Work aroundleadership development willbe accelerated, includingroll out of the core peoplemanagement trainingprogramme, adoption of arevised and comprehensivevalues-based 360, andimplementation of aleadership assessmentcentre, includingpsychometric testing andcoaching feedback. Toaddress challenges aroundraising concerns, targetedDatix training will bedelivered where necessaryto ensure staff are familiarwith the incident reportingprocess, and the Freedomto Speak Up Guardian willbe appointed. To improveperceptions around learningfrom mistakes, divisionalquality governanceprocesses will be reviewedfor consistency in feedbackloops and the profile of ouronline “Lessons Learned”log raised. Coaching for

Dec 2016: A leadership model has beendeveloped, managers' Toolkit launched, coachingframework signed off. Health and wellbeing planis now actively being implemented, with recentactivity including the introduction of some newsports activities, some new health and wellbeingorientated offerings from our catering team, andthe training of a cohort of 15 Mental Health FirstAiders. Staff FFT results have had consistentlygood scores. Risk downgraded to moderate.

October 2016: Risk to be reviewed at the WODcommittee on 22 November 2016

July 2016: A leadership model has beendeveloped, Managers' Toolkit launched, and acoaching framework signed off. The Freedom toSpeak Up Guardian has now been appointed anda new Freedom to Speak Up Policy will be signedoff in August. Our health and wellbeing plan isnow actively being implemented, with recentactivity including the introduction of some newsports activities, some new health and wellbeingorientated offerings from our catering team, andthe training of a cohort of 15 Mental Health FirstAiders.

June 2016: A leadership strategy has beensigned off, and implementation has begun. Themanagers' toolkit design has been finalised, andthe satellite modules are ready to launch in July.The Raising Concerns campaign is ready to beintroduced in July and the Freedom to Speak UpGuardian is in the process of being appointed.This month has also seen the completion of ouremployee health and wellbeing planning process,

01/03/2017 Exec Lead:LouiseMcKenzie

Lead Manager:RebeccaMatthews

Paper 8.0

of 16

improvement training will beprovided for individualsreceiving concerns raised,and further down the line, acampaign will deliver themessage that raisingconcerns is a professionalduty for all staff.

February 2016: Threecorporate actions havebeen agreed to tackle thefollowing areas: training anddevelopment and careerprogression; support to linemanagers; and the fairnessand effectiveness ofincident reporting. Theinternal culture plan andemployee promise havebeen designed to addressthis risk. A separate cultureand engagement workstream has been developedas part of the mergerprogramme.

and our coaching framework.

May 2016: A leadership strategy has beendrafted and is currently awaiting Board sign off. Inthe meantime, the Core People Managementmodule of our leadership development offer hasbeen introduced, the design of our newmanagers’ toolkit progressed and the first of aseries of top team leadership conversationsdelivered at Transformation Programme Board.We have begun planning for the launch of acommunications campaign around raisingconcerns and a coaching framework is indevelopment.

February 2016: March 2014 onwards: NSSCorporate actions: These have included a rangeof ILM Management Development programmeshave been available for staff at band 5 andabove. With Band 8 programmes about tocommence. November 2014: Exit interviewprocess and documentation refreshed. Regularreporting to be implemented from March 2015 toenable evidenced action to be taken.2015 - We will implement a managementdevelopment portal that will provide managers atall bands with a range of tools and resources thatthey can access. Implemented Trust Valuesbased behaviours and these have now beenincluded as part of the Trust new appraisalprocess.

June 2015 - The appraisal process is nowembedded and monitored through PRM’s.Staff survey action plans are being implementedwith positive outcomes.

Paper 8.0

of 16


Risk LevelCurrent

RiskLevelTarget


1487 Agency Rulesand Price Cap

Introduction of agency pricecap may lead to diminsihedsupply and inability to covershifts which could lead tounsafe staffing

MAJOR

15

1/12/15

MODER

12

MINOR

6

May 2016: Monitor haveagreed to an increased2016/17 target for agencyexpenditure for all staffgroups. We continue totrack expenditure againstthe target and work withdivisions to reduce relianceon agency staff and whereused to limit expenditure.

The Trust appealed againstthe initial cap by Monitor,this was partially successfuland the cap was increasedto 8% from October toMarch 2016. Re-submitteda trajectory to bringexpenditure down from 13%in October to achieve 8% byMarch 2016 which has beenaccepted by Monitor.

Implemented controls asdescribed below to supportthe achievement of the cap.

Assess the current ratespaid to agency staff againstcapped rates to identify anythat are over the rate for allstaff groups.

Write to all agencies toindicate our intention to stickto the rates

December 2016: Description of risk amended forclarification. Risk down graded to moderate.

October 2016: Risk to be reviewed at the WODcommittee on 22 November 2016

June 2016: From 1 April the agency spend capapplies to all staff groups. Agency spend for all staffgroups has reduced to 7.3% of total pay in April and6.8% in May

May 2016: Introduced step by step guide formedical locums, similar to the one introduced fornursing.

March 2016: The Trust has been working towardscompliance with the Monitor Agency Rules sinceOctober 2015:

Since November 2015 the Trust has reportedweekly agency use for all staff groups toMonitor;

All nursing agency is with Framework agencies; Safer staffing policy introduced for Nursing in

October for any shifts that need to break glass; Similar process introduced for medical agency in

February for escalated rates; A Tiering system has been established for

nursing agencies to enable agencies meetingthe rate caps to have the chance to fill shifts inadvance of those supplying above cap;

Negotiations are taking place with agencies forall staff groups to ensure compliance with ratecaps and replacement of any off-frameworkagency bookings.

01/03/2017 Exec Lead:Louse McKenzie

Contact:ColleenSherlock

Paper 8.0

of 16

Despite these measures, agency spend hasincreased month on month, due to absence cover,specialing, opening additional beds, and coveringadditional theatre activity.

Divisions are finding it difficult to fill shifts at the ratecap as agencies and locums are asking for ratesabove cap and accepting shifts at other Trusts forhigher rates (this has been raised to Monitor)

Feb 2016: The Trust’s senior nurse leadership teamhave implemented Safer Staffing guidance forwards/ departments to support the management ofthe agency ceiling and provide a governance andassurance process for decision-making to exceedthe cap. This sets out the Trust responsibility forplanning and delivering safe nursing and midwiferystaffing levels to ensure the delivery of high qualitycare to patients and service users.

The Workforce information team are supporting thisby allocating an agreed level of expenditure for eachweek / month which provides a guide to the numberand type of shifts that can be booked within theirindividual cap, and in addition a dashboard has beendeveloped with daily reporting of agency spend andto enable wards / departments to keep track of theirQualified nurse agency use and spend.

In December 2016 the qualified nursing agencyspend was above the trajectory submitted to Monitor,however all requests to exceed the cap wereauthorised in line with the new policy for reasons ofpatient safety.

Paper 8.0

of 16

Risk Closed


Risk LevelCurrent

Risk LevelTarget


1488 Risk of notbeing able torecruit orretain non-EUoverseasnurses due toimmigrationchanges.

i) The Trust has not beengranted Certificates ofSponsorship for currentFilipino candidates (51) inJune.

ii) The introduction of thenew Objective StructuredClinical Examination routefor non-EU nurses isdelaying recruitment process

iii) Existing nurses applyingfor Indefinite leave to remainafter 5 years have to beearning £35k (Band 7)

CATASTR

16

6/7/15

MAJOR

15

MODER

9

i) Trust has reapplied for Julyquota; problem is that nurse is nota shortage occupation. The Trust islobbying MPs and bodies to ask fornurse to be shortage occupation

ii) The Trust is liaising with NMCand Northampton University to getlatest information

iii) The Trust is lobbying MPs andbodies to ask for this to bereconsidered as may impact onexisting staff as well as futurerecruits. A note to staff has beendrafted for Trustnet

Dec 2016: Nursing has been placed onthe shortage occupation list, with nodefinite date for review, but it is likely thatthere will be a review of this in the future(and from October employers have todemonstrate they meet the residentlabour market test). Risk closed as nolonger relevant.

October 2016: Risk to be reviewed at theWOD committee on 22 November 2016

June 2016: Nursing remains on theshortage occupation list, with no definitedate for review, but it is likely that therewill be a review of this in the future (andfrom October employers have todemonstrate they meet the residentlabour market test).

May 2016:i) Certificates of sponsorship now

received as nurses remain on theshortage occupation list for Tier 2visas.The Trust has achieved a 95% passrate (national rate 58% in the OSCEexam since introduction.

iii) Salary cap no longer a requirement.

March 2016:i) The Trust has received Certificates of

Sponsorship for all 47 applicationssubmitted at March 2016. A further 4

Exec Lead:LouiseMcKenzie

LeadManager:ColleenSherlock

Paper 8.0

of 16

are not yet due to apply for CoS.ii) The OSCE process is operational

through Northampton University withnurses having two attempts at theexam. At March 2016 28 Filipinonurses have passed, 6 retakes and 1fail. And a further 8 arrivals inpreparation for first attempt.

iii) The settlement pay threshold of£35000 will not apply to workers onthe shortage occupation list andsince September 2015 this hasincluded Nurses. This only applies tonon-EU staff

Feb 2016: Certificates of sponsorshipnow received.

Paper 8.0

of 16

Current Risk Matrix

Legend

1-3 GreenNegligible Risk

4-6 YellowMinor Risk

8-12 OrangeModerate Risk

15 RedMajor Risk

16-25 Red/RedCatastrophic Risk

Likelihood

Rare Unlikely Possible LikelyAlmostCertain

Severity

1 2 3 4 5

Negligible 1 1 2 3 4 5

Minor 2 2 4 6 8 10

Moderate 3 3 6 9 12 15

Major 4 4 8 12 16 20

Catastrophic 5 5 10 15 20 25

5.4 trust risk register · 2017-01-25 · the trust risk register report provides assurance that...

Documents