appendix 1 - bdct.nhs.uk · 26/09/2016 : risk description: ... september. procurement on new doors...
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Appendix 1
Agenda item 13
Risk number: 1831
Director Owning Risk: Sandra Knight
Risk Register Level: 5 - Corporate
Current Risk Rating: 12 Residual Risk Rating: 12
First entered onto Risk Register:
26/09/2016
Risk description: If the Trust fails to recruit, retain and engage a diverse workforce in the right numbers with the right skills, behaviours and experience to innovate in delivering holistic models of care.
The Trust will be unable to meet the needs of services users, carers and commissioners in terms of delivering high quality, safe, outcome based, patient focused care and support. This in turn will impact on achievement of safer staffing levels, meeting CQC and other regulatory requirements, reducing bank and agency usage and spend and effectiveness in winning tenders where new integrated models of care and working are required.
Gaps in Controls: Lack of vision for an integrated workforce linked to local and WY STP
Pressure on resources and financial constraints affecting the pace at which the vision/strategy and associated plan to shift the organisation from delivery of an agile work programme to a culture in which the Trust becomes a leading exponent of digital healthcare can be progressed Staff survey indicates that staff with protected characteristics feel more discriminated against with fewer opportunities for promotion and career progression than the remainder of the workforce. Lack of a comprehensive strategy to roll out cultural competence training across the organisation Current graduates not trained and in sufficient numbers to deliver holistic care, and not fully prepared for the work environment particularly in in-patient settings
Open actions: Most recent action update: 1 Involvement in local and West Yorkshire
STP Workforce Planning arrangements to support the development of an integrated vision and strategy for an integrated workforce
People Strategy ratified at October Board. Kings Fund Research into factors driving improvement in some WRES metrics due to deliver in March / April 2020 . West Yorkshire & Harrogate MH Workforce Collaborative appointed a project manager to support joint provider planning and delivery of priorities
Date Entered : 09/01/2020 13:18 Entered By : Sarah Firth
4 Scrutiny of KPIs in the Board Integrated Performance Report to ensure achievement of expected levels of performance and bringing performance back on track where targets are not being met.
new dashboards are being developed for the committees as the Trust moves towards having a standard format.
Date Entered : 27/05/2020 14:24 Entered By : Fiona Sherburn
7 On-going development of partnership/links with and agreed actions with universities, further education colleges using the new student loan model and apprenticeship levy to enrol sufficient numbers of students with the right skills to ensure there is a pipeline of talented staff to recruit from.
new apprenticeships cohort in place from April 2020.
Date Entered : 27/05/2020 14:29 Entered By : Fiona Sherburn
9 Implement the Workforce Race Equality Scheme action plan and Workforce Disability Equality Scheme action plans once approved by the Board
Action plan approved and is being implemented and monitored via the EDI steering group.
Date Entered : 31/01/2020 08:53 Entered By : Fiona Sherburn
14 Ongoing support for managers to make best use of management information reports
on-going support and coaching is being provided particularly around e rostering. Roll out of the safe care module completed.
Date Entered : 27/05/2020 14:31 Entered By : Fiona Sherburn
16 Apprenticeship strategy in place to support growing our own staff.
strategy in place and new apprentices recruited to.
Date Entered : 22/05/2020 14:09 Entered By : Fiona Sherburn
17 Sharing perspectives programme , being rolled out in 2018/19
Programme rolled out to targeted team and this particular programme is now embedded in core modules of the Leadership and Management Development Passport. Entered by S. Knight 30.01.2019
Date Entered : 30/01/2019 12:16 Entered By : Debbie Daniel
18 Implement the WDES in 2019 once approved by the Board
WDES approved. Action plan underway and will be monitored via the EDI steering group
Date Entered : 31/01/2020 08:55 Entered By : Fiona Sherburn
Closed actions:
2 Workforce and BME employment strategies and action plans continue to be monitored through the WTSG, Directors' Transformation Governance Meeting, FBIC and Board
3 Focus groups organised to discuss the staff survey results linked to BME staffs' perceptions of opportunities for career progression and promotion and experiences of discrimination
5 Continued growth in the staff bank and roll out of e-rostering to all inpatient areas, IHTT, First Response and District Nursing and follow on implementation of the safe care module
6 As a follow up to the deep dive workforce planning report at FBIC, map the projected number of vacancies linked to LTO and turnover by across areas to support planning to manage the gaps and enable skill mix change/transformation
8 Launch the Centre for Excellence for Support Staff Development and engage/attract in as associates, West Yorkshire stakeholders across the health and social care sector in the health and social care and training provider sectors. Achieve the quality kite mark for our own in house training provision
10 Develop wiht the Leadership Academy for Yorkshire and the Humber a culture change programme that raises awareness and understanding across all teams of the behaviours that will support achievement of a diverse workforce that feels valued.
11 Develop a cultural competence train the trainer programme that will enable staff to work effectively with diverse teams
12 Ensure effective e-rostering reports that provide the information in support of ensuring that all rostered areas have the right numbers of staff and most cost effective, skilled workforce to deliver safe, quality care
13Ensure the development of a digital strategy and action plan that will support transformation of ways of working and embed a culture that empowers patients and staff
15 Comprehensive recruitment and retention action plan, focusing on preceptorship, recruitment and retention and streamlining recruitment processes.
19 Dedicated apprenticeship officer approved by SLG on a FTC to support the implementation of apprenticeship strategy.
Risk number: 2046
Director Owning Risk: Gaynor Toczek
Risk Register Level: 5 - Corporate
Current Risk Rating: 15 Residual Risk Rating: 10
First entered onto Risk Register:
20/06/2018
Risk description: Organizational / individual practice not consistent with good information governance. Breaches of information governance law (DPA / GDPR) resulting in significant financial penalties and / or reputational damage
Open actions: Most recent action update: 2 To establish the human resources required to
fulfill the new statutory deadlines for GDPR There is a need to review staffing post-COVID 19 crisis. Currently no agency cover, 1 colleague due to go on maternity leave and 1 partially redeployed.
Date Entered : 15/06/2020 09:20 Entered By : Gaynor Toczek
Closed actions:
3 GDPR Forward plan to be monitored at IGG bi-monthly
Risk number: 2102
Director Owning Risk: Patrick Scott
Risk Register Level: 5 - Corporate
Current Risk Rating: 12 Residual Risk Rating: 8
First entered onto Risk Register:
15/05/2018
Risk description: Three-quarters of people who kill themselves while on a psychiatric ward do so by hanging or strangulation. Risk of service user harm through ligature within inpatient or CMHT environment
Gaps in Controls: Ligature risks may still arise as they cannot be fully designed out. There is the requirement for acceptable risks to be locally managed within service areas. This is now taking place, exception report template has been drafted and will be used to present
exceptions from February meeting of LERS onwards
Open actions: Most recent action update: 6 Issues identified regarding the process of
ligature assessment within the inpatient wards
ligature risk assessments have been updated for ACMH in view of the full door alarms at ACMH now being live. LMH full door alarms are still in the fitting/testing phase and due to go live mid september. BORIS now have a meeting arranged to discuss further developments - previously on hold due to COVID-19
Date Entered : 04/09/2020 14:02 Entered By : Simon Long
7 Programme of works underway to replace bedroom doors and windows in key bedrooms across all wards assessed as ' high risk' within new ligature risk assessment framework, and introduce other measures such as new anti-barricade mechanism and patient call alarms, following recent approval by the Trust Board.
Phase 1 completed and scoping work has commenced on phase 2 of doors and windows to commence in November. Board paper to be presented in October and FBIC paper in September. Procurement on new doors will be placed prior to 18th September to enable works to commence. All ligature risk assessments are completed with Manchester Tool and in date with mitigation of risk identified
Date Entered : 13/09/2020 13:15 Entered By : Phillipa Hubbard
Risk number: 2151
Director Owning Risk: Patrick Scott
Risk Register Level: 5 - Corporate
Current Risk Rating: 8 Residual Risk Rating: 9
First entered onto Risk Register:
07/09/2018
Risk description: Sudden 'no deal' Brexit from the EU in March 2019. NHSE has identified risks as follows:
Workforce: 5% of NHS workforce (not including primary care) and 7% of social care workforce may be affected. However, UK government has committed to allow EU citizens already in the UK to settle here, which should offset majority of this.
Supply Chain: 83% of medical products are imported to the UK from (or through) other EU countries, including medical devices & clinical consumables. 45% of medicines used in the UK are imported from the EU. Tariffs, trade changes and customs delays could all affect supply.
Research and innovation: Risks to reduced collaboration with EU (including clinical trials), divergence on regulations, access to innovative treatments and income (including funding for clinical research staff)
Reciprocal Healthcare. Some UK residents who are currently living in EU may wish to return home with the majority of those assessed as being elderly, which may potentially cause increased load on UK healthcare in general. Also risk to more complicated cost recovery processes for EU nationals receiving treatment from UK facilities.
Operations: System readiness and access to services across borders
EPRR and pandemic planning: A risk to information sharing and systems across borders. Potential loss of shared intelligence and early warning systems from European Centre for Disease Prevention and Control (ECDC).
Procurement & competition: risk to disruption to new contracts
Data & IG: Risks to longer term alignment and implications for services across borders (EU regulation and GDPR collaboration).
Medicines & devices regulation: risks to disruption and delays in access to new products in the UK. At the request of UK government manufacturers have assured that they will hold at least 6 weeks supply to cover the period immediately after Brexit. Health organisations are not to stockpile drugs and medicines.
Public health: maintaining public health standards in UK legislation
Gaps in Controls: Awareness level of staff re potential Brexit issues
BCPs cannot deliver products if they are not available
Open actions: Most recent action update:
2 Monitor and respond to all NHSE letters and guidance
The UK future relationship with the EU currently remains unknown. The country officially left the
Open actions: Most recent action update: EU on 31 Mar 20, but negotiations on future agreements with the EU
single market and customs union are continuing during the current 'transition period' and will determine how aspects of health and social care are delivered and accessed from 1 Jan 21 onwards. In the meantime, during the transition period the UK is still abiding by EU regulations and is entitled to the same benefits as other EU member states.
With only 3 months now left for agreements to be reached, the potential for a 'light deal' Brexit is emerging more strongly. The risk remains that some (or all) required trade, customs and legislative agreements will not be reached in time. National contingency planning for the end of the transition period focusses on the need to mitigate any potential disruption to delivery of all categories of medical supplies. Following advice from DHSC during the run-up to Brexit in March 2020, BDCFT focussed on ensuring contingency plans met the requirements and arrangements were in place to quickly respond if required. In the event, Brexit has largely been overtaken and overshadowed by Covid-19. However, the arrangements put in place to address Brexit issues remain extant.
Previously considerable work has been carried out both nationally and within the Trust to prepare for, and mitigate the possible consequences of a no-deal EU Exit. This work will continue up to and beyond the deadline. In addition to the work already carried out, the following actions are being taken:
Continue to monitor further guidance from NHS England and other relevant bodies and ensure identified actions are implemented. Horizon scanning and amendment of planning arrangements as required, for example concurrency with winter plans and a potential second Covid-19 surge. Communications with staff, patients and visitors covering the implications and key messages around Brexit. Attendance at any regional workshops and exercises (when arranged). Working with local and regional health partners to ensure plans are integrated across the system. Via the CCG, seeking assurance regarding adult social care. This should continue to be commissioned by Local Authorities who continue to be responsible for ensuring there are no gaps in care.
The continued uncertainty around the nature, timing and consequences of Brexit remain unclear
Open actions: Most recent action update: and this presents significant challenges. National,
regional and local EPRR working groups will continue to monitor these and, where possible, identify and implement mitigating actions to address them.
Regional workshops will be held and led by NHSI/E as and when further guidance is issued
Date Entered : 04/09/2020 12:03 Entered By : Patrick Scott
Closed actions:
1 Communications Strategy 3 Draft a Brexit plan if/as required
Risk number: 2207
Director Owning Risk: Greg Soffe
Risk Register Level: 5 - Corporate
Current Risk Rating: 15 Residual Risk Rating: 10
First entered onto Risk Register:
09/01/2019
Risk description: IT / Clinical systems affected by a cyber incident, originated from within or from outside the organisation. Critical impact on IT and clinical system access, impacting on clinical and administrative activities
Gaps in Controls: Large number of systems to monitor and extensive programme of work
Review of all systems time consuming and OpenVAS discovery continuing
Open actions: Most recent action update: 3 Working towards Cyber Essential Plus We have booked a new CE+ audit commencing
next month. the new audit will give us CE initially before heading to CE+
Date Entered : 17/07/2020 10:30 Entered By : Greg Soffe
7 CE+ gap audit and analysis We are booked with CORS team for a remediation progression, and we are working on it at the moment.
Date Entered : 17/07/2020 10:31 Entered By : Greg Soffe
Closed actions:
1 Vulnerability scanning of system continuing
2 Mobile device management being introduced
4 Recruitment of Cyber Security Team
5 Implementing ELK log SIEM software to store and analyse system logs and events.
6 Implement DDOS Defence on the corporate website.
Risk number: 2266
Director Owning Risk: David Neil Gibson
Risk Register Level: 5 - Corporate
Current Risk Rating: 16 Residual Risk Rating: 8
First entered onto Risk Register:
20/06/2019
Risk description: Physical assault of inpatient ward staff by service users 97% of physical assault incidents take place on inpatient wards. The data reporting history reports that the likelihood of such an incident is high for staff working on inpatient wards. Staff at risk are those who come into direct contact with patients on inpatient wards, not only inpatient clinical staff but also support staff such as housekeeping and estate maintenance staff. Risk of physical assault of staff member by service user 97% of physical assault incidents take place on inpatient wards. The data reporting history reports that the likelihood of such an incident is high for staff working on inpatient wards. 2 out of the 4 RIDDOR incidents in 2018-19 were related to physical assault by service user on staff member. Only 1% (12 out of 1254) of all reported incidents have a moderate or more severe impact to the staff member The wards with highest prevalence of incidents are DAU (28 incidents per year per bed) and ATU (18 incidents per year per bed), followed by Clover Ward (12 incidents per year per bed). There are approximately 3 incidents per year per bed on adult mental health wards. HSE inspection found that the Trust's arrangements at ACMH were not sufficiently robust to mitigate the risks highlighted above. However the HSE Improvement An action plan is required to complete for ACMH by early October 2019.
Gaps in Controls: All staff not being 100% compliant with training Documented risk assessments to denote why teams have the required level of training Shifts not always fully staffed
Open actions: Most recent action update: 4 Develop a Policy to document the process for
violence & aggression risk assessments within high risk areas
Policy review in Apr-20 deferred due to conflicting C19 priorities. Policy remains current and in-date whilst community based-revisions are pending
Date Entered : 21/04/2020 14:40 Entered By : David Neil Gibson
Closed actions:
3 To ensure learning from improvement notice and new MAV risk assessments for ACMH site, adopt approach for risk assessments within community teams, working in partnership with Assistant GM's and nominated deputies: Complete team specific risk assessments for teams based on organisational structures.
Risk number: 2342
Director Owning Risk: David Neil Gibson
Risk Register Level: 5 - Corporate
Current Risk Rating: 12 Residual Risk Rating: 6
First entered onto Risk Register:
21/11/2019
Risk description: Medical devices not receiving planned maintenance at the appropriate frequency (current Trustwide compliance for annual planned maintenance as of 31-Aug-20 is 91% for inpatient areas and 68% for community areas. This includes all devices across Trust services (overall compliance = 71%)Impact on patient care due to malfunctioning medical device, based on the device not having received planned maintenance at the appropriate frequency. There is a risk that a number of the devices listed as 'archived' in the inventory are still in use and are not in date for planned maintenance and calibration. If devices are not maintained or calibrated at the appropriate frequency there is an increased risk of failure which can impact on diagnosis or patient care.
Gaps in Controls: 19% of devices haven't received planned maintenance in past 12 months (identified as missing
clinical teams advised not to use until planned maintenance completed)
Open actions: Most recent action update:
1 Continue to share inventory updates via MDWG members as a reminder to ensure any out of date devices in their teams are reported to maintenance provider for planned maintenance to take place
31-Aug-20 inventory update shared with all MDWG service leads (and CC'd GM's) outlinung to service leads the following: ACTIONS
Any devices maintained over 12 months ago (red text in the attached) should not be used until annual planned maintenance is complete on the device.
Contact our maintenance provider (LTHT) to arrange planned or reactive maintenance, see contact details listed here- they are available to visit Bradford on Monday, Wednesday and Fridays)
NB. LTHT have a schedule of visits to Trust premises which they inform teams of their visits, however for belt & braces share medical device safety updates with team members reminding them of responsibilities to check devices are in date for planned maintenance and calibration before use
Any device that has not received 12-monthly planned maintenance should not be used by clinical staff.
Date Entered : 11/09/2020 14:39 Entered By : David Neil Gibson
Risk number: 2370
Director Owning Risk: Patrick Scott
Risk Register Level: 5 - Corporate
Current Risk Rating: 12 Residual Risk Rating: 6
First entered onto Risk Register:
20/03/2020
Risk description: Covid-19. Impact of Covid-19 on the Trust's ability to operate and maintain safe, high quality services during the pandemic period' Reduction in staff availability/skill this will be based on a 50% then 75% reduction in staffing. Individual services will be greatly reduced and some services cease. Closure of wards due to an outbreak of Covid-19.
Gaps in Controls: Not all staff may have accessed or read the amended policies.
National rollout of PPE equipment may take time to arrive to the trust which may lead to a lack of equipment. It is anticipated all trusts will receive further stocks by 22 March 2020 Plans to address risk to inpatient sites should outbreak of COVID -19 materialise. Currently underway. Uncertainty over staff availability/skils mix in operating under reduced staffing ratios
Decision to assess when non essential services could safely be closed to redeploy staff to other areas IT infrustructure - availability of equipment to staff working at home, bandwidth and connectivity
and issues relating to home working. Staff availaibility across all sectors
Open actions: Most recent action update: 3 Develop and finalise plan to address risk to
inpatient sites if Covoid -19 outbreak occurs within the trust.
Cohorting plans and building works identified on 3 acute areas including separate lounge space, toilet facilities and outside space these plans have been approved for Ashbrook, oakburn and maplebeck and currently work is due to commence in October. this will provide separate areas for COVID 19 positive patients, and isolation areas whilst swabbing results return
Date Entered : 13/09/2020 13:06 Entered By : Phillipa Hubbard
4 Daily review of staff availability/skill mix in wards and teams. Daily assessment of need to close non essential services to redeply staff if required to clinical areas.
monitored through daily safer staffing dashboard as part of safer care and discussed at daily lean management report outs. Concerns esculated and staff bank provided. business continuity plans currently being revised and planneda further session with NEDS and key Execs at the beginning of October to quality assure BCP's across operational and coporate services
Date Entered : 13/09/2020 13:08 Entered By : Phillipa Hubbard
Closed actions:
1 Staff to be notified that policies have been amended, clinical managers/team leaders to ensure staff have read and understood. Staff to be clear about where policies are located when they are updated/amended.
2 Infection control team to advise if PPE stocks not replenished and review BCP. To liaise with other trusts and GP practices to see if surpus stock available To inform Incident control centre and Silver Command of situation in order to escalate.
5 To review availability of IT equipment to support staff to carry out roles - both available now in the the trust and also that equipment that is on order. Complete stress testing of IT networks and systems - where problems identified develop SMART action plans to address.
Risk number: 2416
Director Owning Risk: Delphine Fitouri
Risk Register Level: 5 - Corporate
Current Risk Rating: 8 Residual Risk Rating: 4
First entered onto Risk Register:
11/09/2020
Risk description: Virgin Media's basis for arguing that the minimum spend commitment should commence from tariff implementation, rather than actual contract start, is unclear. Virgin Media are challenging the minimum contract spend associated with the new tariffs that were agreed contractually in November 2019. Virgin Media have indicated that the new tariff arrangements implemented in May 2020 should run for a 12-month term which would take the term up to May 2021, which is beyond the end of the formal contract end date. If this challenge was upheld costs of up to £100k would be incurred.
Open actions: Most recent action update:
1 Contract scheduled under review with support from Trust lawyer and follow up headed letter to be considered as a formal response to supplier
Additional contract schedules from the Framework supplied to lawyer on 14/09/2020
Date Entered : 16/09/2020 13:28 Entered By : Delphine Fitouri
Risk number: 2417
Director Owning Risk: Gillian Findley
Risk Register Level: 5 - Corporate
Current Risk Rating: 15 Residual Risk Rating: 10
First entered onto Risk Register:
15/09/2020
Risk description: Potential for adverse publicity on the back of findings from CQC investigations. Risk of financial penalty or breach of license
Open actions: Most recent action update:
1 Review of serious incidents has taken place. Regular meetings with CQC and further submission developed as required. Implementation of findings from serious incidents is being audited.
Risk number: 2418
Director Owning Risk: Patrick Scott
Risk Register Level: 5 - Corporate
Current Risk Rating: 16 Residual Risk Rating: 12
First entered onto Risk Register:
15/09/2020
Risk description: Potential that 0-19 contract is under resourced due to financial settlement, which may impact on quality of services. Potential that staff are unable to fulfil the full requirements of the contract due to financial shortfall
Open actions: Most recent action update:
1 Review of strategic programs highlighted the gap in resources. Commissioners approached to discuss the shortfall in funding. Services are being provided in accordance with the service specification.
Appendix 2
Name of author: Paula Reilly Title: Risk and Safety Manager Date paper written: 17 September 2020