enc k report to the trust board of directors held in ... · enc k report to the trust board of...

Enc K REPORT TO THE TRUST BOARD OF DIRECTORS

HELD IN PUBLIC ON 26 JULY 2016

BOARD ASSURANCE FRAMEWORK – updated July 2016

Trust objectives supported by this paper

• The paper supports the achievement of all Trust Objectives through the underpinning strategy of ensuring that the Trust is well governed and works effectively in partnership

Link to Board Assurance Framework

• The paper contributes to the ongoing development of the Board Assurance Framework itself.

Purpose of the paper The paper aims to provide members of the Trust Board with assurance that key, high level risks agreed by the Board relating to the delivery of the Trust’s Strategic Objectives are being managed appropriately.

A full discussion took place at the Risk and Audit Committee on the 20 July 2016.

Summary of key points

• The Board Assurance Framework (BAF) records Executive-led assessments of the key risks relating to the delivery of the Trust’s Strategic Objectives and the level of internal control to prevent these risks occurring.

• Risk scores have been reviewed by Executive Risk Owners. There has been no movement in current risk scores since the BAF was last presented to the Committee / Board.

• The inherent risk score for BAF(10) has been increased to reflect the unmitigated risk for 2016/17.

• For each risk, the summary sheet demonstrates the balance of internal and independent assurance available. This also indicates whether any source of independent assurance has provided a ‘limited’ or ‘none’ assurance opinion. This can be cross referenced to the main content body of the BAF.

• There has been some movement in effectiveness ratings for individual risk controls as highlighted in the body of the BAF. The conclusion of discussion with risk owners is that this movement has not impacted on aggregate risk scores.

• Alignment is demonstrated between entries on Trust risk registers and the eleven high-level risks identified on the BAF. A review of risk registers with the Trust Risk Manager has identified all risks with a score of 12 or more that have a direct link to the achievement of the Trust’s strategic objectives. These have been mapped onto the BAF.

Board Action required The Board is asked to review and comment on the attached BAF and specifically:

i) Review the adequacy of controls and assurances ii) Note the alignment of risks from risk registers iii) Input into the ongoing development of the BAF iv) Accept current levels of risk post the application of controls

Author: Judith Green, Associate Director of Corporate Affairs FOR COMMENT

BOARD ASSURANCE FRAMEWORK 2016/17

INHERENT

RISK*

CURRENT

RISK*

Effectiveness of

Controls

No. of Trust

Assurances

^ inherent risk scores incorrectly reported in last report (no controls) (post controls)

BAF (1) DNQFailure to effectively deliver healthcare impacts on the safety and quality of patient experience,

regulatory compliance and loss of confidence of the wider community.15^ 8 18

%

21

BAF (2) CFORisk that we do not maintain financial stability due to failure to deliver the financial plan resulting

in requirements for additional CIPs or reduction in level and standard of quality of our services.15 12 11

%

26

BAF (3) DHRFailure to ensure that the Trust has a motivated, suitably trained and engaged workforce impacts

on operational performance, transformational change and achievement of strategic objectives.14 10 8

%

14

BAF (4) DHRFailure to ensure that the Trust recruits staff in the right numbers and with the appropriate

breadth of skills and competencies to deliver high quality services now and in the future.14 9 4

%

14

BAF (5) CEORisk that insufficient leadership capacity and capability prevents necessary transformational

change to deliver efficient, high quality services12 12 1 15

BAF (6) COORisk to clinical service viability due to failure to meet nationally defined quality standards or

unfavourable changes to the commissioning of services (genetics / epilepsy / CAMHS / HV).13 12 2 9

BAF (7) CEOFailure to engage effectively with partner organisations and the local community threatens the

ability of the Trust to deliver its strategic ambition.12^ 8 1 18

BAF (8) MD

Failure to engage with our clinicans prevents the development / implementation of an effective

clinical strategy to deliver high quality services that responds to the needs of patients and other

health and social care partners

15 10 1 19

BAF (9) COO

Failure to ensure that the required IT infrastructure and strategy is in place to deliver clinical

services and support clinical strategy and transformation impacts on the Trust's ability to improve

quality and transform services.

18 16 4%

12

BAF (10) CFOFailure to deliver major capital projects to budget and on time impacts on the rest of capital

programme and causes operational disruption and/or poor patient experience (inherent risk rescored July

2016)

15 12 1%

9

BAF (11) COOCapacity constraints impact on our ability to deliver planned activity and manage demand

impacting on operational efficiency, service quality and financial performance.13^ 9 2 10

BAF (12) CFOFailure to manage the Trust's cash position would result in the Trust not being able to satisfy its

obligations in respect of pay and non-pay costs.20 10 1 6

* risk score rounded from aggregate scores overleaf % one or more sources of assurance - limited or none

(movement since last review)

BAF RISKS

No. of

Independent

Assurances

Version 2.0 - updated July 2016

23 5 0

11 6 1

11 2 0

2 10 1

5 5 0

2 3 2

11 6 0

13 1 0

3 7 0

8 0 0

6 4 0

6 0 0

Board Assurance Framework - July 2016

Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 2016

LINKED TO LEAD

C L S C L S

BAF (1)Failure to effectively deliver healthcare impacts on the safety and quality of patient experience,

regulatory compliance and loss of confidence of the wider community4.3 3.5 15.2 SO (1) / SO (5) / SO (9) 4.0 2.0 8.0 DNQ

BAF (2)Risk that we do not maintain financial stability due to failure to deliver the financial plan resulting in

requirements for additional CIPs or reduction in level and standard of services.4.3 3.5 15.1 SO (8) / SO (1) 4.0 3.0 12.0 CFO

BAF (3)Failure to ensure that the Trust has a motivated, suitably trained and engaged workforce impacts

on operational performance, transformational change and achievement of strategic objectives.4.2 3.3 13.9

SO (6) / SO (1) / SO (2) /

SO (3)3.7 2.6 9.6 DHROD

BAF (4)Failure to ensure that the Trust recruits staff in the right numbers and with the appropriate breadth

of skills and competencies to deliver high quality services now and in the future.3.8 3.6 13.8

SO (6) / SO (1) / SO (2) /

SO (3)3.0 3.0 9.0 DHROD

BAF (5)Risk that insufficient leadership capacity and capability prevents necessary transformational

change4.0 3.0 12.0 ALL SO's 4.0 3.0 12.0 CEO

BAF (6)Risk to clinical service viability due to failure to meet nationally defined standards or unfavourable

changes to the commissioning of services (genetics / epilepsy / CAMHS / HV).3.9 3.4 13.0 SO (3) / SO (1) / SO (8) 4.0 3.0 12.0 COO

BAF (7)Failure to engage effectively with partner organisations and the local community threatens the

ability of the Trust to deliver its strategic ambition4.0 3.0 12.0

SO (9) / SO (1) / SO (2) /

SO (3) / SO (4) / SO (5) /

SO (8)

4.0 2.0 8.0 CEO

BAF (8)Failure to engage with our clinicans prevents the development / implementation of an effective

clinical strategy that responds to the needs of patients and other health and social care partners5.0 3.0 15.0

SO (1) / SO (2) / SO (3) /

SO (4) / SO (5) / SO (9)5.0 2.0 10.0 MD

BAF (9)

Failure to ensure that the required IT infrastructure and strategy is in place to deliver clinical

services and support clinical strategy and transformation impacts on the Trust's ability to improve

quality and transform services.

4.3 4.3 18.3 SO (7) / SO (1) / SO (8) 4.0 4.0 16.0 COO

BAF (10)Failure to deliver major capital projects to budget and on time impacts on the rest of capital

programme and causes operational disruption and/or poor patient experience.5.0 3.0 15.0 SO (7) / SO (1) / SO (8) 4.0 3.0 12.0 CFO

BAF (11)Capacity constraints impact on our ability to deliver planned activity and manage demand

impacting on operational efficiency, service quality and financial performance.3.8 3.5 13.3 SO (8) / SO (1) 3.0 3.0 9.0 COO

BAF (12)Failure to manage the Trust's cash position would result in the Trust not being able to satisfy its

obligations in respect of pay and non-pay costs.5.0 4.0 20.0 SO (8) / SO (1) 5.0 2.0 10.0 COO

Consequence (C) x Likelhood (L) = Risk Score (S)

3 or less = Low Risk

4 to 7* = Medium Risk

8 to 14* = High Risk

15 to 25 = Very High Risk

Risk Score Colour Coding (*note - decimal points derived from average scoring methodology used at Trust Board Awayday. Scores do not therefore align fully to risk scoring

methodology within Risk Management Strategy / Risk Register)

INHERENT RISK (no

controls)CURRENT RISKBOARD ASSURANCE FRAMEWORK RISKS 2016/17

version 2.0 2


Strategic Objectives

SO (1) To provide healthcare of the highest standard available in the UK SO (6)

SO (2) To work in partnership with others to reshape healthcare for children in Sheffield SO (7)

SO (3) To develop and expand our role as a provider of specialist services for children SO (8)

SO (4) To expand the Trust's role as an expert provider of specialist pathology services SO (9)

SO (5) To be a national leader in research and education in children's healthcare

Control Ratings Assurance Ratings (from Internal Audit Opinions)

Evidence of regular monitoring available

Results of monitoring satisfactory / majority positive

Control recently introduced, not fully embedded

Control process is not delivering adequate assurance

Shared ownership of controls means Trust not fully 'in control' / concerns about processes outside

the Trust's Control

Not controlled

No controls in place

No evidence available

None

No Assurance can be provided as weaknesses in control, or consistent non-compliance with key

controls, could result [have resulted] in failure to achieve the system’s objectives in the areas

reviewed.

Significant Assurance can be provided that there is a generally sound system of control designed

to meet the system’s objectives. However, some weakness in the design or inconsistent application

of controls put the achievement of particular objectives at risk.

AMBER

To ensure that the Trust has an appropriately trained and supported workforce

Underpinning Objectives

LimitedLimited Assurance can be provided as weaknesses in the design or inconsistent application of

controls put the achievement of the system’s objectives at risk in the areas reviewed.

To ensure that facilities and equipment used by the Trust are of high quality

To ensure that robust arrangements are in place to ensure financial stability

RED

Full Assurance can be provided that the system of internal control has been effectively designed to

meet the system’s objectives, and controls are consistently applied in all areas reviewed.Full

Significant

GREEN

To ensure that the Trust is well governed and works effectively in partnership

version 2.0 3


BAF Ref Number

Principle Risk

What controls are in place to

assist in securing the delivery of

the objective?

Assurance - are there

controls where no

assurance is available?

BAF (1) SO (1)Performance management of

operational and quality targets

Operational Performance

reports to Trust Board T Jun-16

SO (9) T Apr-15

SO (5)

Increased waiting times in

some clinical specialities

due to capacity issues

see BAF (11)

A&E unplanned re-

attendance rate above 5%

target at 8.1%

Audit results

presented to Quality

Committee Feb 16

(Ctte assured)

CO

O

ac

tion

ed

New 18 Week target in

CAMHS from 01/04/16Reporting to be

developed

CO

O

Ap

r-16

T

Tboard

May

2016

Trends from serious

incidents / root cause

analysis identified:

* communication with roma

slovak communities

Trust Board

Quality and

Operational

Performance

Reports

Integrated Governance

reports to Trust Board and

Quality Committee

Ma

r-16

CQINN agreed for

15/16 re

communication with

Roma communities -

work to continue

Failure to effectively

deliver healthcare

impacts on the safety

and quality of patient

experience, regulatory

compliance and loss

of confidence of the

wider community

RISK OWNER: DNQ

By

wh

en

Action plans (or

reference to action

plans) to meet gaps

in control or

assurance

LeadAction to meet gaps

Control - do the assurances

identify that any of the

controls are not working or

not fully implemented? Are

further controls required?

Gaps in control or

assurance

Link to

Strategic

Objective

How does

this risk link

to the Trust's

objectives

and

priorities?

Co

ntro

l ratin

g

Risk Controls

BAF RISKS Evidence that shows risks are

being managed and objective

being delivered

Re

ce

ive

d

Tru

st (T

) or In

de

pe

nd

en

t (Ind

)

Ref # of

entry of

high level

risk on

corporate /

divisional

risk

registers

As

su

ran

ce

ratin

g (In

d)

R770

R794

R828

R832

R842

R867

R876

R896

R899

R900

R904

R905

R913

R915

R916

R922

R925

R927

Assurance

What monitoring

arrangements

are in place?

Internal

monitoringCross Ref

Robust programme of

divisional review by

Executive team in place

(framework paper approved

by Trust Board)

DN

Q

Board Assurance Framework 4


BAF Ref Number

Principle Risk

By

wh

en


Gaps in control or

assurance

Link to

Strategic

Objective

Risk Controls AssuranceInternal

monitoringCross Ref

* Theatres Update provided to

Quality Ctte in Dec

15

* Violence & Agression at

Becton (specific case) Staff training & policy

review re

assessment process

DN

Q

ac

tion

ed

Underperformance against

targets (CQUIN) for

completion of discharge

summaries identified.

Action plan in place

as reported to Trust

Board in Sept 15 and

Quality Ctte in Oct

2015

CO

O

Ma

r-16

Participation in patient

experience surveys to

benchmark quality of care

Trust Board &

Quality

Committee

Patient Experience Reports -

benchmarked as averageInd Jun-15

Additional patient

experience metrics /

benchmarking data to be

developed

Patient Experience

Strategy to be

developed

DN

Q

TB

C

Implementation of Friends and

Family Tests to guage

patient/carer and staff opinions

Trust Board &

Quality

Committee

Friends & Family Test

comments reviewed - majority

positive / low response rate Ind monthly

Low response ratesWorking with Comms

Team & Volunteers

to move to paper

based collection

DN

Q

Ju

l-16

Implementation of Infection

Prevention & Control measures

Trust Board &

Quality

Committee

Infection Prevention &

Control Annual Report

2014/15

Jun-15

Infection Prevention &

Control Reports

Feb-16

Internal audit of Trust’s

management of CQUIN

schemes

Ind Oct-15 % Sigificant assurance

opinion re negotiation /

limited opinion re delivery

On

go

ing

16/17 CQUINs agreed T Mar-16

Inpatient / Outpatient Quality

Dashboards (at Trust and

divisional level)T monthly

Reporting to Quality

CommitteeT Jun-16

Hospital Intelligent Monitoring

Score Ind May-15

New system of NRLS

reporting in place

fro

m a

mb

er

-

july

20

16

Implementation of

recommendations /

increased reporting

of CQUIN

performance - now

included within

performance reports

cont:// ………………


deliver healthcare




compliance and loss


wider community

RISK OWNER: DNQ

Agreement and monitoring of

Quality priorities and targets

(Quality Report / CQUINS)

T



BAF Ref Number

Principle Risk

By

wh

en


Gaps in control or

assurance

Link to

Strategic

Objective


monitoringCross Ref

Process in place to review

learning from outside the Trust

and implement relevant

recommendations

Trust Board &

Quality

Committee

Patient's First & Foremost

Action Plan progress update -

all actions implemented and

are embedded in Trust

process / procedure

T May-15

May 2014 Care Quality

Commission Visit

Inspection Report

Ind May-14

June 2016 Care Quality

Commission Visit - initial

feedback

Ind Jun-16 TBC

Mental Health Act Visits Ind Dec-15

Action Plan T Feb-16

Sheffield Safeguarding

reviewInd Dec-15

Action Plan T Feb-16 Work in progress

External regulation by Monitor Trust Board Monitor Governance Rating

for 2015/16 - Green Q3

(confirmed by Monitor)

Ind Mar-16 Requirement of NHS FT

Code of Governance for

external governance

assessmement to be

carried out every 3 years

Self Assessments to

be presented to

Board Committees in

July

AD

CA

Ju

l-16

Co-ordination of schedule of

Internal assessments of care

environment

* PLACE Assessments Assessment results for the

main hospital, Becton &

Ryegate scored well

compared to the national

average with Becton above

average for all standards

Ind Mar-16

New menu in place.

Identified as quality

priority. Required

focus in starving

times and hydration

DN

Q

TB

C

* 15 steps challenge

T

Done through Mock

CQC inspections

(below)

DN

Q

Reported within

Integrated

Governance

reports to Trust

Board and

Quality

Committee

cont:/ ….


deliver healthcare




compliance and loss


wider community

cont:/……..


deliver healthcare




compliance and loss


wider community

Subject to external regulation by

the Care Quality Commission

Trust Board &

Quality

Committee



BAF Ref Number

Principle Risk

By

wh

en


Gaps in control or

assurance

Link to

Strategic

Objective


monitoringCross Ref

* Back to the Floor programme

involving members of the Board

Verbal feedback to Trust

Board from back to the floor

visitsT monthly

Looking to formal

report from Back to

the Floor Visits within

Integrated

Governance Reports

DN

Q / A

DC

A

Ma

y-1

6

* Mock CQC Inspections Commenced / Weekly

programme in place with

Governor and NED

involvement - reported

through Quality Taskforce

update to Board

T Mar-16

* Cleanliness Audits Infection Control Reports to

Trust Board and Quality

CommitteeT May-16

* Six monthly nurse staffing

reviewJun-16

* Monthly nurse staffing

reportsmonthly

Internal Audit - Data Quality -

Safe Staffing

Ind Mar-16

% Limited Assurance Opinion -

6 recommendations

including one high

Implementation of

Recommendations DN

Q

Ju

n-1

6

Management of Sickness

absence rates

Finance &

Resources

Committee and

Trust Board

Workforce metrics snapshot

(FR&C) / Quarterly Workforce

Information Report (TB) T

monthly /

TB - May

16

Mandatory training programme

in place to ensure that staff

have appropriate skills

Finance &

Resources

Committee and

Trust Board


(FR&C) / Quarterly Workforce

Information Report (TB)T

monthly /

TB - May

16

Policies provide framework for

staff to operate within

Execitve Risk

Management

Cttee

Assessed though routine

inspection process by

external regulators

Outdated policies

indentified being updated

* CQC Inspection Ind May-14

* Mental Health Act

Compliance Inspection Ind Dec-15

External accreditation / peer

reviews *

HTA AccreditationInd date?

* Nursing Medical Council Ind date?

TEG / Trust

Board

Safer staffing nursing

establishments agreed and

monitoredT



BAF Ref Number

Principle Risk

By

wh

en


Gaps in control or

assurance

Link to

Strategic

Objective


monitoringCross Ref

* Burns Peer Review Ind date?

* T&O Peer Review Ind Mar-15

Clinical audit programme in

place which identifies shortfalls

in best practice

Quality

Committee



Quality CommitteeT May-16

Identified need for more

effective links between

clinical audit programme

and internal audit through

risk and audit committtee

Risk and Audit

Committee presented

with Clinical Audit

Programme - May

2016

DN

Q

ac

tion

ed

Quality

Committee

Robust process for

monitoring the release of

NICE Guidance . Integrated

Governance reports to Trust

Board and Quality Committee T May-16

Some areas of concern

mainly relating to the

completion of baseline

assessments and the

issues are currently being

addressed by the relevant

Divsions.

Delays to be

escalated to

Divisional Clinical

Director - progress

being made but often

guidance require

shared working

across organisations

DN

Q

on

go

ing

Participation in External Peer

Review Programme

TEG / Quality

Committeesee above Ind

as

above

Subject to external accreditation

/ review of relelevant services

TEG / Quality

Committee

Annual reports to Quality

Committee Ind

As per

work

prog

Participation in Civil Eyes

benchmarking service

TEGClinic Utilisation data

reported to TEGInd Mar-15

Board Presentation re

benchmarking data presented

to March Board

Ind Mar-16

Quality impact assessment of all

CIPs

Quality

Committee

Standing item on Quality

Committee agenda T Jun-16

Issues with level of data in

QIA submissions

Trust incident reporting policy

and process

Divisional

Monitoring /

Executive Risk

Management

Ctte / Quality

Ctte / Exception

reports to Risk &

Audit Ctte



Quality Committee

T May-16

DATIX business case to be

presented to TEG

NRLS reporting (1 April to 30

September 2014) - Ind Apr-15 ?

Controlled Drugs Incident

reporting T April

cont:/ ….


deliver healthcare




compliance and loss


wider community

TB

C

Quality Assurance

Manager to maintain

database of external

reviews

DN

Q

No central database of

external reviews



BAF Ref Number

Principle Risk

By

wh

en


Gaps in control or

assurance

Link to

Strategic

Objective


monitoringCross Ref

Trust Board Learning from Mistakes

League Trust ranked 56 out

of 231 Trusts, with a score of

Good

Ind Mar-16

SUI action plan update and

exception reporting from

corporate risk register reviewed

by risk and audit committee

Risk & Audit

Committee


Report demonstrates robust

reporting culture -majority

related to Patient Safety and

have a consequence graded

as negligible which required

no or minimal intervention.

T May-16

Complaints monitoring Quality

Committee


Report T May-16

Quarterly themetic

complaints report to

be developed

DN

Q

Ma

y-1

6

IG Toolkit Compliance IG Committee Trust Board PaperT Nov-15

Internal Audit ReportInd Mar-16

Board self assessment against

Monitor's Quality Governance

Framework

Trust Board Input from self assessment

collated and presented to

BoardT Jun-14

Now incorporated within

Monitor's Well Led

Framework

Performance Management of

compliance with PDR

completion

fro

m a

mb

er

-

july

20

16

Finance &

Resources

Committee and

Trust Board


(F&RC) / Quarterly Workforce

Information Report (TB)

T

F&RC

monthly /

TB - May

16

Duty of Candour in place

Trust Board Exception reporting T

Internal Audit Review

scheduled within 16/17

Internal Audit Plan

DN

Q

Qtr 2

Risk & Audit

CommitteePolicy approved by F&RC T Oct-13

New requirement for

Freedom to Speak Up

Guardian

Ch

air

Se

p-1

6

Reported within Quarterly

Workforce ReportT May-16

Standing item on R&AC

agenda- no exceptions

reported in last 12 months

T

SID appointment approved T

CoG

July

2015

cont:/ ….


deliver healthcare




compliance and loss


wider community

Arrangements in place for staff

to raise concerns in confidence

Nomination to be

made by Board



BAF Ref Number

Principle Risk

By

wh

en


Gaps in control or

assurance

Link to

Strategic

Objective


monitoringCross Ref

Equality & Diversity System in

placeDiversity &

Public

Engagement

Group

Paper presented to Trust

BoardT Jun-14

Trust Board Paper - progress

updateT Jan-15

Trust Values Workshop for

Bod / CoGT May-15

Programme in place for

embedding of Trust values

Finance &

Resources

Committee /

Trust Board /

Council of



BAF Ref NumberGaps in control or

assurance

Principle Risk


assist in securing the delivery

of the objective?


controls where no


BAF (2) CO (8)

Cycle of business planning

papers presented to Trust

Board and F&RCT

Nov 15 -

Mar 16

CO (1) Assessment against Monitor's

hallmarks of quality strategic

planning - positive

assessment

T Jun-14

Refined 16/17 planning round -

Board paper setting approach

and timetableT Sep-15

FRC Presentations re revised

internal delivery plans to

address timing of new

appointments / increased

capacity via the hospital

development programme.

T Mar-16

Internal Audit on Business

Planning Processes -

significant assuranceInd Apr-16

Draft Operational Plan for

16/17 including financial plan

submittedT Feb-16

Monitor feedback on draft

submission - no material

concernsInd Mar-16

Results of 15/16 annual plan

review - Monitor letterInd Aug-15

Cross Ref

Ref # of

entry of

high level

risk on

corporate /

divisional

risk

registers






Action to meet

gapsB

y w

hen

Le

ad

Action plans (or

reference to action

plans) to meet gaps

in control or

assurance

Link to

Strategic

Objective

How does

this risk link

to the

Trust's

objectives

and

priorities?

What monitoring

arrangements

are in place?

Internal

monitoring

R726

R832

R842

R857

R867

R913

Receiv

ed

Assurance

Assu

ran

ce ra

ting

(Ind

)

Tru

st (T

) or In

dependent (In

d)

Risk Controls

Co

ntro

l ratin

g

Evidence that shows risks are


being delivered

BAF RISKS

Trust Board /

Finance &

Resources

Committee

Clearly defined business

planning process

Risk that we do not

maintain financial

stability due to failure

to deliver the financial

plan resulting in

requirements for

additional CIPs or

reduction in level and

standard of services

RISK OWNER: CFO




assurance

Principle Risk

Cross RefAction to meet

gapsB

y w

hen

Le

ad

Link to

Strategic

Objective

Internal

monitoringAssuranceRisk Controls

Month 2 finance report -

ahead of plan ytd T Jun-16

Monitor Risk Ratings (out of

4): Liquidity: 4 Capital

Service Cover: 1

I&E Margin: 1 I&E Margin

variance: 4 Overall: 2

FRR (3) Qtr 4 2015/16 -

confirmed by Monitor

Ind May-16

Capital Investment Team /

TEG review and prioritisation of

capital fundingFinance &

Resouces

Committee

Paper outlining process taken

by CIT to allocate Capital

resources as part of 15/16

annual planning processT May-15

Risk identified re

underestimate of funding

for IM&T new build

requirements

Split of costs to be

allocated across

new build / general

contingency funds

actio

ne

d

IM&T Capital Plan and Future

Risks paper to FRCT Jan-16

Capital Investment Team

minutes presented to FRCT Mar-16

Capital programme internal

audit follow up Ind Oct-15

x3 outstanding

recommendations

implementation of

action monitored by

R&AC

CF

O

Oct-1

5

Divisional Performance

Managament Framework in

place - more robust escalation

process for divisional

performance management in

16/17 with executive

involvement based on

achievement of plan.

Divisional

performance

reviews with

Exec Team

Framework Paper approved

by F&RC

T Apr-15

Monitoring of delivery of activity

/ income plan

Monthly reports of income

against plan / financial

Reports by Division T Jun-16

S&CC and Medicine

Divisions underpeforming

against plan

Presentation to

F&RC in Dec 15

and Mar 16

CO

O

actio

ne

d

Control of costsT Jun-16

Business Case processes

Vacancy Control panel T Mar-16

Agency Spend Controls

cont:// ……….. Risk

that we do not

maintain financial



plan resulting in

requirements for

additional CIPs or



Risk identified re future

IM&T funding not identified

within current capital

programme

T

Management of Financial

performance

Trust Board /

Finance &

Resources

Committee

Monthly reports of expenditure

against plan / financial reports

by Division

S&CC and Medicine

presentations to F&RC

Jun-16




assurance

Principle Risk


gapsB

y w

hen

Le

ad

Link to

Strategic

Objective

Internal


Internal Audit Report -

Temporary Staffing (Limited

Assurance)Ind April

% Recommendations madeImplementation of

RecommendationsDHR

T Dec-15

Internal reporting to FRC

quarterly

Internal reporting to

commence

CF

O

Sep

-16

Audit of use of agencies on

national framework

Included in 16/17

internal audit plan

DH

R

Effective pay controls Payroll Data Analytics KPMG

Audit Report - test majority

greenInd Oct-15

Recommendations made Implementation of

internal audit

recommendations

DH

R

Dec-1

5

Arrangement for Managing

Salary Overpayments (report

to FRC)Ind Jan-16

Capital YTD spend £6,868k

underspent due to timing of

New Build invoicesT Mar-16

Prospective review of activity to

be undertaken on rolling basis

to determine potential shortfalls

at speciality level linked to

mitigating action plans.

Finance Department

T ?

source of assurance needs

to be identified

Transformation & Efficiency

Programme

Robust planning of 2015/16

CIPsT May-15


Programme Management

Office

Internal Audit Report on CIP/

PMO - limited assurance

FU (April 16) - x3 outstanding

medium priority

recommendations

IndOct-15

Apr-16

% While finding a high degree

of resilience re CIP

forecasting, 2 medium risk

recommendations re

delivery of CIPs

Progress against

recommendations

to be reported

through routine

reports to R&AC

CF

O

Oct-1

5

Use of external consultancy

support to increase productivity

Performance management of

delivery efficiencies at Trust

and divisional levelT Jun-16

cont:// …………... Risk

that we do not

maintain financial



plan resulting in

requirements for

additional CIPs or



Board agreed risk adjusted

CIP Plans / target >

requirement

Month 2 Transformation &

Efficiency Programme Report -

30% delivery against CIP

target

Finance &

Resources

Committee /

Trust Board /

TEG

fro

m a

mb

er

- Ju

ly 2

016

New control arrangements in

place for agency spend -

weekly return to Monitor




assurance

Principle Risk


gapsB

y w

hen

Le

ad

Link to

Strategic

Objective

Internal


BAF (2)Planning for 2016/17 CIPs Feedback from CIP Summit

reported to FRCT Nov-15

Assessment of Trust position

against Carter

Recommendations

FRC

Paper to March FRC T Mar-16

Contingency level identified

within Trust financial plan

Trust Board /

FRC

Financial reportingT Sep-15

Abilty to draw down loan from

FTFF

Trust Board /

FRC

Board resolution to draw down

loan - Sept 15 Confirmation

of loan draw down (Board min

135/15)

Further Loan approved and to

be drawn down in quarter 4

16/17

T Nov-15

Commissioning of independent

review of internal financial

controls

Risk & Audit

Committee


Budgetry Control and KFS Ind Mar-16

Trust Board /

FRC

Finance Report reporting

Liquidity ratio (4) - month 2T Jun-16

Risk of impact of NHS

debtors on the Trust cash

position

Payments plans

agreed

CF

O

on

go

ing

Income and Debtors - Internal

Audit Report Limited

Assurance opinion givenInd Jan-16


Recommendations

CF

O

Cash Committee reports to

FRCT Mar-15

SLAM reports / meetings with

commissioners T

Action notes

Contracting arrangements in

place with commissioners

Corporate

Planning Team

SLAM reports / meetings with

commissionersT

Effective contract managament

arrangements in place Corporate

Planning Team

Internal Audit report follow up

Ind Oct-15

recommendations madeImplementation of

recommendations

CF

O

Ap

r-16

Engagement with national tariff

agenda

Trust Board Progress updates from CEO

or CFO at Trust Board (Board

mins) T Dec-15

Dec-15

cont:/ …………

Risk that we do not

maintain financial



plan resulting in

requirements for

additional CIPs or



Cash Management Strategy in

place with a more thorough

focus on the 13 week cash flow

forecast, working capital

management and a loan

application to ITFF.

Corporate

Planning Team

Progress updates from CEO

or CFO at Trust Board (Board

mins)T

Robust joint QIPP planning

approach and commitments in

place with commissioners built

into the contract so therefore

less risk

Involvement through Alliance in

specialist paediatric tariff top

up representations

Trust Board




assurance

Principle Risk


gapsB

y w

hen

Le

ad

Link to

Strategic

Objective

Internal


BAF (2)

Prudent assumptions within

financial plan around charity

income

Hospital Project

Board

Reporting to Hospital Project

BoardT Dec-15

Finance &

Resources

Committee

Quartely reporting to F&RC

on charitable income T Mar-16

Tight financial controls in placeRisk & Audit

Committee

SOFI exception reportingT Apr-16

including procurement

Oct-14 Poor compliance with

purchase orders

Collaborative approach re

imminent national

reconfiguration of Genetic

Laboratories in order to

mitigate financial risk re loss of

service.

Trust Board /

TEG

Update to Trust Board by

Clinical Director - Board

endorsement of approach

T Jul-15

See BAF (6)Update due to come

to Trust Board

CO

O

Jan

-16

Implementation of appropriate

Trust Investment Strategy

Risk & Audit

Committee

Treasury Management Policy

revised and approved by

Trust BoardT Jul-15

cont:/ …………

Risk that we do not

maintain financial



plan resulting in

requirements for

additional CIPs or



CF

O

% Reporting purchase

order non

compliance to RAC

quarterly

Internal Audit report on

contract management -

limited assurance

Ind

actio

ne

d



BAF Ref Number

Principle Risk


assist in securing the delivery of

the objective?


controls where no


BAF (3) SO (6)

Board approval of HR

Strategy T Jun-12

SO (1)

Formation of Trust

Education Group - paper to

FRCT Jan-16

SO (2)

Progress against strategic

objectives T

Oct-15

SO (3)


(FR&C) / Quarterly

Workforce Information

Report (TB)

T

monthly

June 16

/ TB -

May 16

Monitored via

divisional reviews

May 2016 - 4.2% - stress

and anxiety top reason

Gap in control of

management of stress

related sickness absence

Resilience

workshops

delivered across

the Trust

Sickness absence

policy to be

reviewed

Oct-1

5


(FR&C) / Quarterly


Report (TB)

T

* Trust average May 2016:

89% against 85% target

FRC -

June 16

/ TB -

May 16

Finance &

Resources

Committee and

Trust Board

Mandatory training programme

in place to ensure that staff

have appropriate skills

Failure to ensure that

the Trust has a

motivated, suitably

trained and engaged

workforce impacts on

operational

performance,

transformational

change and

achievement of

strategic objectives.

RISK OWNER: DHR

Evidence that shows risks

are being managed and

objective being delivered

Key HR Strategy deliverables

identified within SO (6) and

progress routinely monitored

and reported

Finance &

Resources

Committee and

Trust Board

Finance &

Resources

Committee /

Trust Boardfr

om

gre

en

-

Ju

ly 1

6

AssuranceGaps in control or

assurance

Internal

monitoring

What monitoring

arrangements

are in place?






Link to

Strategic

Objective

How does

this risk link

to the

Trust's

objectives

and

priorities?

Co

ntro

l ratin

g

Risk ControlsAction to meet

gaps

BAF RISKS

R726

R828

R832

R899

R913

R915

R922

R925

On

go

ing

Le

ad

DH

R

Ju

l-16

Cross Ref

Ref # of

entry on

corporate

risk

register

By w

hen

HR Strategy due to be

refreshed

Review HR

Strategy in line with

timetable for review

of strategic

direction

Action plans (or

reference to action

plans) to meet gaps

in control or

assurance

Assu

ran

ce ra

ting

(Ind

)

Receiv

ed

Tru

st (T

) or In

dependent (In

d)

Trust Board

DH

R

HR Strategy in place

Management of sickness

absence rates



BAF Ref Number

Principle Risk


assurance

Internal

monitoring

Link to

Strategic

Objective


gaps

Le

ad Cross Ref

By w

hen

BAF (3)

Internal Audit Follow Up

report - Mandatory Training Ind Feb-16

Performance management of

PDR completion compliance

fro

m a

mb

er

Ju

ly

2016 Finance &

Resources

Committee and

Trust Board


(FR&C) / Quarterly


Report (TB) - 80%

for May 2016T

FRC Jun

16 / TB -

May 16

Revalidation process for

medical staff in placeTrust Board

Annual compliance report

presented to Trust Board -

Board approved submission T Sep-15

Participation in external

accreditation / review of

relevant clincial services

TEG / Clinical

Governance

Committee

Annual reports to Clinical

Governance Committee Ind

as per

work

prog

No central database of

external reviews

SEE BAF (1)

Participation in local quality

management visits from Health

Education Yorkshire and

Humber

Annual Deanery

Quality

monitoring visit

Reference within CEO

Report to TB

Ind Nov-14

May 2014 Care Quality

Commission Visit Inspection

ReportInd May-14

CQC Action Plan Progress

Report (Int Gov Report):

* Improve Mandatory

Training & PDR rates

T Dec-15

* Trust average May 2016:

89% against target of 85%

Communications Strategy in

place with key objective

focused on internal

communications

Finance &

Resources

Committee

Progress against objectives

reported to FRC every 6

months T Jun-16

Programme of Staff

Engagement Trust Board

WRES ReportInd Jun-16

% Actions set out in

Jun Board paper

DH

R

JNCCHWB CQUIN action plan

updateT Jul-16

Health &

Wellbeing

Group

Staff Attendance at Open

Forum Meetings TSpring

16

Staff Friends and Family

Test resultsInd

Subject to external regulation -

CQC

Trust Board

cont:/ ……. Failure to

ensure that the Trust

has a motivated,

suitably trained and

engaged workforce

impacts on operational

performance,

transformational

change and

achievement of


results of Workforce Race

Equality Standard report

indicates lower BME staff

engagement



BAF Ref Number

Principle Risk


assurance

Internal

monitoring

Link to

Strategic

Objective


gaps

Le

ad Cross Ref

By w

hen

BAF (3)

Communications Report to

TEG T May-16

HSJ Top 100 Best Places to

work placement Ind Jun-15

Staff Survey Results 2015Ind Mar-16

Staff Survey 2014 Action

PlansT May-15

Work programme for

Embedding of Trust values in

place

Finance &

Resources

Committee /

Trust Board /

CoG

Trust Board Paper -

progress updateT Jan-15

Trust Values Workshop T May-15

Clinical Excellence Awards

Programme

Trust Board Awards for 2015/16 T Jun-16

BAF (4) SO (6)

Strategic Workforce

Planning paper identified key

workforce challenges

affecting clinical divisions

Feb-15

SO (1) Update presented to Board Feb-16

SO (2)

Retirement planning audit

undertaken

Finance &

Resources

Committee

Paper to Finance &

Resources Committee

T Sep-15

SO (3)

Engagement with divisions to

understand workforce

requirements to feed into

external workforce planning

submisison to HEE

TEG Annual Submission made by

Trust

T date ?


fro

m g

reen

-

Ju

ly 2

016 F&R Committee

/ Trust Board


Strategy

T Jun-12

HR Strategy out of date

and due to be refreshed

(aligned to refresh of Trust

Strategic Direction)SEE BAF (3)

DH

R

Ju

l-16

Key HR Strategy deliverables

identified within SO (6)

Trust Board Progress against strategic

objectives T Oct-15

Finance &

Resources

Committee /

Trust Board

cont:/ ……. Failure to

ensure that the Trust

has a motivated,

suitably trained and

engaged workforce

impacts on operational

performance,

transformational

change and

achievement of


Finance &

Resources

Committee /

Trust Board /

TEG

R794

R828

R900

R905

R913

R922

R925


the Trust recruits staff

in the right numbers

and with the

appropriate breadth of

skills and

competencies to

deliver high quality

services now and in

the future.

RISK OWNER: DHR

TProgress being made to embed

workforce planning into

business planning cycle



BAF Ref Number

Principle Risk


assurance

Internal

monitoring

Link to

Strategic

Objective


gaps

Le

ad Cross Ref

By w

hen

BAF (4)

Agency / Locum Booking

Controls

TEG New control arrangements in

place for agency spend -

weekly return to Monitor T Dec-15

Internal reporting to FRC

quarterly

Internal reporting to

commenceC

FO

Fe

b-1

6

TEG Paper T Dec-15

Audit of use of agencies on

national framework

Include in 16/17

internal audit plan

DH

R

Ma

y-1

6


Temporary Staffing (Limited

Assurance)Ind Apr-16


Recommendations

DH

R

Trust Board Updates to Trust Board.

Planned discussion in

autumnT Jun-16

Outside Trust Control

Staff

Communications

Message issued

* Six monthly nurse staffing

reviewT May-16


reportsT Jun-16

Internal Audit - Data Quality -

Safe StaffingInd Mar-16

% Limited Assurance Opinion -

6 recommendations

including one high

Implementation of

Recommendations

DN

Q

Ju

n-1

6

Nurse Recruitment - recruited

to all vacant posts and to

account for natural attrition /

maternity leave

Trust Board


reportsT May-16

Consultant Job Planning


Consultant Job Plans and

Management of Consultant

Annual Leave

Ind Feb-16

% Limited Assurance Opinion Implementation of

Recommendations MD

Engagement with key

stakeholders re nurse training

places

Trust Board

Verbal updates to Trust

Board - ANP course

developed by Shef Uni - 1st

student intake Sep 15

T

Growing own researchers as

academics w/i Academic Unit

of Child Health

Research &

Innovation

Board

Annual and mid year report

to Trust Board T Jun-16

Trust BoardSafer staffing establishments

agreed

Ju

l-16

DN

Q

Positions on influencing bodies

includng National Social

Parthership Forum (DHR),

Executive of National Staff

Council (DHR) and Chair of

Y&H HRD Network (HRD) re

risks to EU workforce /

workforce sustainabilty

following EU Referendum Shortfall identified -

business case to TEG

cont:/ ...........


the Trust recruits staff

in the right numbers

and with the

appropriate breadth of

skills and

competencies to

deliver high quality

services now and in

the future.



BAF Ref Number

Principle Risk


assurance

Internal

monitoring

Link to

Strategic

Objective


gaps

Le

ad Cross Ref

By w

hen

Targets set around efficiency of

recruitment processes

Quarterly Workforce

Information Reports T May-16

Monthly workforce metrics

snap shot reports to F&RC T Jun-16 variability in performance

highlighted

Internal Audit reportInd May-15

Recommendations made

re KPIs

Implementation of

recommendations

DH

R

BAF (5) SO (1)


fro

m g

reen

-

july

2016 F&R Committee

/ Trust Board


Strategy

T Jun-12

HR Strategy due to be

refreshed in alignment with

refresh of Trust Strategic

DirectionSEE BAF (3)

DH

R

Ju

l-16

R726

R794

SO (2) Key HR Strategy deliverables

identified within SO (6)

Trust Board Progress against strategic

objectivesT Oct-15

SO (3)

Effective divisional

management arrangements in

place

TEG Divisional structure agreed

and implemented from Aug

2012T Jul-12

SO (4)

Substantive appointments

made at AD level within

divisionsT Jul-15

SO (5)

Clinical Director

reappointments for three

year termsT Aug-15

Succession planning for

clinical leaders (Clinical

Director posts)

SO (6)

Balanced and stable Board Board Balance of completeness

statement (Annual Report)T May-16

One NED vacancy from

01/04 / One from 01/09 /

New Chair from 01/09

Appointments

approved by CoG

Ch

air

acti

on

ed

SO (7)

Substantive Executive Team

- no vacancies / interim

positions & low turnover

(Annual Report)

T May-16

Chief Executive -

resignation with effective

from 25/09

CEO Recruitment

underway

Ch

air

Sep

-16

SO (8)

Effective Executive

Recruitment Process -

Appointment of Chief Nurse T Jul-15

SO (9)

Review of balance of board

by Board Nominations

CommitteeT Sep-15

fro

m g

reen

- j

uly

2016

Risk that insufficient

leadership capacity

and capability

prevents necessary

transformational

change

RISK OWNER: CEO

Finance &

Resources

Committee /

Trust Board /

TEG



BAF Ref Number

Principle Risk


assurance

Internal

monitoring

Link to

Strategic

Objective


gaps

Le

ad Cross Ref

By w

hen

BAF (5)

Appointment of interim CIO and

progress being made for

recruitment of substantive post

fro

m a

mb

er

- ju

ly

2016

Board Reported in CEO Report

(sept 2015) / reported

substantive appointment

made to Nominations

Committee (April 2016) -

draft minutes

T Apr-16

Trust Executive Group in placeTEG

TEG minutesT May-16

T Jan-16

PDR process in place

fro

m a

mb

er

-

july

2016 Finance &

Resources

Committee /

Trust Board


(FR&C) / Quarterly


Report (TB)T Dec-15


Programme

fro

m g

reen

-

july

2016

Finance &

Resources

Committee

monthly programme report T Dec-15

Assessment against Monitor's

Well Led framework

Board Self Assessment by Board T Oct-14

Some assurance gaps

idenfified in review of

Board self assessment by

360 Assurance

Implementation of

recommendations

AD

CA

Sp

ring

2016

CQC Well Led component

Ind May-14

Initial discussion taken place

with clinical team leaders.

Draft paper discussed at

TEG in Jan re wider Trust

leadership programme

Leadership programmes in

development

TEG

Risk that insufficient

leadership capacity

and capability

prevents necessary

transformational

change

RISK OWNER: CEO



BAF Ref Number

Principle Risk



of the objective?


controls where no


BAF (6) SO (3)

SO (1)

SO (8)

Workstream in place to review

Clinical Strategy

TEG TEG awayday held Sept 2015 /

Board paper presented

outlining next steps

T

Sep-15

Strategy Development Group

established to undertake work

from Oct 15

TofRef / Mins from monthly

Strategy Development Group

meetings

T

Feb-16

Peer Review - TEG paper (Dec

15) outlining issues to be

addressed. Action plan agreed Ind Mar-15

CO

O

Sp

ring

2016

> progress made in increasing

leadership capacity through

investment agreed by TEG

(one post outstanding)

Additional ED consultant

appointed from April 2013 /

recruitment to second post

complete

Action plan /

investment agreed

by TEG Dec 2015 -

Agreed investment

in Trauma clinical

lead and rehab lead

T Dec-15

Action to meet

gapsAssurance

Gaps in control or

assurance

TEG

Risk to clinical service

viability due to failure to

meet nationally defined

standards or

unfavourable changes to

the commissioning of

services.

RISK OWNER: COO

Ref # of

entry on

corporate

risk

register

Evidence that shows risks are


being delivered

Receiv

ed

Tru

st (T

) or In

dependent (In

d)






R687 T

Cross RefB

y w

hen

Le

ad

Review of compliance with

nationally defined standards -

Plan submitted to

commissioners to achieve

compliance with funding

identified

Checking on receipt of

letter from commissioners

confirming this

How does

this risk

link to the

Trust's

objectives

and

priorities?

BAF RISKS What

monitoring

arrangements

are in place?

Link to

Strategic

Objective

Major Trauma Centre -

Interim designation as

paediatric trauma centre

Risk Controls

Lack of progress against

recommendations /

benchmarking results .

Declining scores

Interventional Radiology

No issues raised following peer

review of compliance achieved

against standards.

Co

ntro

l ratin

g

Internal

monitoring

Action plans (or

reference to action

plans) to meet gaps

in control or

assurance

Assu

ran

ce ra

ting

(Ind

)

TEG



BAF Ref Number

Principle Risk

Action to meet

gapsAssurance

Gaps in control or

assuranceCross Ref

By w

hen

Le

ad

Link to

Strategic

Objective

Risk ControlsInternal

monitoring

BAF (6) Epilepsy Surgey TEGUpdates to Trust Board via

CEOT

No response received to

proposal

Joint proposal for a North

Eastern Centre for Epilepsy

Surgey under preparation with

Leeds and Newcastle trusts

Tier 4 CAMHS

reprocurement TEG T Jun-16

Trust expressed interest to

NHSE as a potential provider

External staffing review

undertaken

Review of existing cost base

and pricing submitted to

commissioners Feb 2015

Feasabilty study undertaken in

relation to development

opportunities

Specialist Pathology TEG

Genetic Laboratory

DesignationUpdate to Trust Board by

Clinical DirectorT Feb-16

Collaborative approach being

taken forwardApproach endorsd by Board

Genomic Medical Centres Update to Trust Board by

Clinical DirectorT May-15

outcome of submission to first

tender stage reported by CEO Nov-15

GMC bid successful Ind Dec-15

Health Visting & Family

Nurse PartnershipTEG Update to Trust Board re

reduced funding / high level of

staff turnover / vacanciesT Jun-16

Redesign of Service to meet

reduced funding

Project group set up by Trust

and LA

Reporting lines not yet

defined

x8 additional health visitors

recruited / push back re

contract arrangements

Reporting

arrangements for

project group to be

reviewed

cont:/ …

Risk to clinical service

viability due to failure to

meet nationally defined

standards or

unfavourable changes to

the commissioning of

services.

AS

APC

OO

fro

m a

mb

er

- ju

ly

2016

fro

m a

mb

er

- ju

ly 2

016

Trust Board updated by CEO /

COO re national procurement

progress. Paper to FRC - June

2016 updating Board on

regional procurement timetable

Continue discussions /

negotiation with STH and other

partners to develop a

framework for joint working

and collaboration

External support necessary

to support bid



BAF Ref Number

Principle Risk

Action to meet

gapsAssurance

Gaps in control or

assuranceCross Ref

By w

hen

Le

ad

Link to

Strategic

Objective


monitoring

BAF (7) SO (9)

SO (1)

SO (2) WTP Principles agreed by

Board T Feb-16

SO (3) Monthly WTP Board update T Mar-16

SO (4)

Paper on successful Vanguard

Application and Value

Proposition submission T Dec-15

SO (5)

Paper to Board on Working

Together Programme on

Children’s Surgery and

Anaesthesia

T Dec-15

SO (8)Board approval of Federated

Board proposalsT Jun-16

Routine verbal updates within

Chair's report to Board - Board

minutesT Mar-16

Stakeholder Engagement with

partners delivered through

membership / involvement in

wide range of forums / groups

Report to Trust Board on

progress to achievement of

Trust Objectives

CO

O

Ma

y-1

6

Specifically - CEO holds joint

Chair role of Children's Health

& Wellbeing Board

Transforming Sheffield Forum

(CEO)

NHS CEOs part of Public

Health Reform Agenda being

led by LA

Sheffield Provider's Alliance

Forum

City-wide Digital Footprint

Working Group (COO)

R687

R900

R905

R915

R927

Development of infrastructure

to deliver STP for South

Yorkshire - to emerge out of

Working Together

Participation in Working

Together Programme (WTP)

Monitor's Code of

Governance (E.2.2) states

that the Board should

review the effectiveness of

these processes and

relationships annually and,

where necessary, take

proactive steps to improve

them.

T

Board Dec 2014 approved the

continuation of current

infrastructure funding for a

further 12 mnths

Dec-14

Jul-15 Stakeholder

inflience audit in

progress through

the Strategy

Development

Group which will

inform development

of stakeholder

engagement plan

TEG

Trust Board

T

Evidence of successul

engagement is LA working

with Trust to redevelop

Children's Services following

reduction in public health

funding rather than retender

Failure to engage

effectively with partner

organisations and the

local community

threatens the ability of

the Trust to deliver its

strategic ambition.

RISK OWNER: CEO



BAF Ref Number

Principle Risk

Action to meet

gapsAssurance

Gaps in control or

assuranceCross Ref

By w

hen

Le

ad

Link to

Strategic

Objective


monitoring

BAF (7)Commissioner relationship

management

Board 2015/16 Contracts signed with

NHSE and CCGT Jun-16

Involvement in transformation

plans re the mental health and

emotional wellbeing of children

and young people in Sheffield /

COO member of Emotional

Health and Wellbeing group

TEG / Board Paper to Board re Future in

Mind

T Sep-15

Diversity & Public Engagement

Group set up

Quality

Committee Terms of reference T

Establishment of Youth Forum Patient Story slot at June

BoardT Jun-16

Relationship with Charity /

CEO and Chair hold Charity

Trustee positions

BoardVerbal reports to Board from

Chair / CEO from Charity

Trustees' Meetings

Tmonthly

(ad hoc)

Children's Alliance - CEO /

CFO / MD and DoN sub

committees

Board

Verbal updates to Board on

specific issues, ie top up tariff

T Nov-15

Development of the Academic

Unit of Child Health

Research &

Innovation

Board

Annual and mid year report to

Trust Board

T Sep-15

Chairmanship of Local

Research Network

CLARC

Academic Health Science

Network

Building strategic partnerships

with industry to increase

commercial income /

encourage innovation

TEG / Board Annual and mid year report of

Research & Innovation

Directorate

T Sep-15

fro

m a

mb

er

-

july

2016

cont:/ Failure to engage



local community

threatens the ability of


strategic ambition.



BAF Ref Number

Principle Risk

Action to meet

gapsAssurance

Gaps in control or

assuranceCross Ref

By w

hen

Le

ad

Link to

Strategic

Objective


monitoring

BAF (7)

Building strategic international

links to increase commercial

income and Trust profile

TEG / Board New Born Screening /

Genetics development with

Bangledesh / India, China and

Kurdistan

CEO role as Chair of

Partnership Board re Genomic

Medical Centre and Genetic

Laboratories

TEG / Board Update to Board on award of

GMC status

T Dec-15

Membership of Test Bed

Programme Steering Group

(CEO)

Host of Operational Delivery

Networks (paediatric critical

care / neurosciences)

TEG / Board ODN Annual Reports / ODN

presentation to Board

T Dec 15

Feb 16

Working with Commissioners

re potential role as host for

Clinical Network for Children’s

Surgery and Anaesthesia

TEG / Board Update paper to TEG and

Board (as part of WTP/STP

updates)

T Jun-16

`Continued development of

effective working with Council

of Governors

Effectiveness review of Council

of GovernorsInd

Spring

2014

Due for 2015/16 Schedule

effectiveness review

AC

DA

Sep

-16

Involvement of Governors in

Trust Business reported in

Annual Report T May-15

Membership and

Engagement Strategy for

review

Work with lead

governor to develop

engagement plans

for 2015/16

AC

DA

Au

tum

n 2

016

cont:/ Failure to engage



local community

threatens the abilty of


strategic ambition.

Trust Board /

CoG

fro

m g

reen

- j

uly

2016



BAF Ref Number

Principle Risk

Action to meet

gapsAssurance

Gaps in control or

assuranceCross Ref

By w

hen

Le

ad

Link to

Strategic

Objective


monitoring

BAF (8)SO (1)

SO (2)

Management engagement with

clinicans through:

SO (3) SO

(4)

TEG T monthly

SO (5)

SO (9)

JNCC / LNJC Minutes and Terms of

Reference of JNCC / LNJC

meetings

T monthly

Staff Governors Composition of Council - all

Staff Governor positions filled

(website)

T Jun-16

Staff Open Forums Second round of meetings

held with good feedback

receivedT Dec-15

Effective divisional

management arrangements in

place

TEG Divisional structure agreed and

implemented from Aug 2012 T Jul-12

Clinical Director

reappointments for three year

termsT Aug-15

Succession planning for

clinical leaders (Clinical

Director posts)

TEG New Build Project Board -

terms of reference T

EDMS project group terms of

reference T

Implementation of internal

communications and

engagement plan

TEG Communications Strategy -

approved by F&R Committee /

Six monthly updates to Board

Sub Committee

T

Jan

2015 /

June

2016

TEG Strategy Away Day T Sep-15

Board Strategy Development Group

Terms of Reference T Dec-15

TEG Epilepsy

TEG Research & Innovation Board

minutes T

R913

Clinical involvement in

agreeing / implementing

clinical strategy

Project management

arrangements involve clinical

representaiton

Minutes and Terms of

Reference of TEG meetings

Failure to engage with

our clinicans prevents

the development /

implementation of an

effective clinical strategy

that responds to the

needs of patients and

other health and social

care partners RISK

OWNER: MD



BAF Ref Number

Principle Risk

Action to meet

gapsAssurance

Gaps in control or

assuranceCross Ref

By w

hen

Le

ad

Link to

Strategic

Objective


monitoring

BAF (8)TEG Genetics

Staff Survey TEG Staff Survey Results & Action

Plan Ind Mar-16

Induction Programmes - Trust /

Junior Doctors'

Induction ProgrammeT Ongoing

Development of CIP

Programme

TEG CIP Summit - feedback given

to Nov FRC T Nov-15

Updated Junior Doctors /

Consultant Handbook

HandbooksT Nov-15

Appointment of x2 Deputy

Medicial Directors

Board

Nominations

Ctte

Minuted discussion re

succession planning T Apr-16

Planning for Junior Doctors

Strike Action

Trust Reaction

Group

Minutes from TRG meeting /

updates to Board / FRC T Mar-16

Use of Clinical Microsystems

methodology

TEG TEG Paper

T Nov-15

Implementation of programme

of Back to the floor visits for

Board and CoG

fro

m a

mb

er

- Ju

ly

2016 Board Verbal feedback to Trust

Board from back to the floor

visits

T monthly

Feedback planned

to be incorporated

and reported within

Integrated

Governance

Reports

DN

Q / A

DC

A

Ma

y-1

6

Failure to engage with

our clinicans prevents

the development /

implementation of an

effective clinical strategy

that responds to the

needs of patients and

other health and social

care partners RISK

OWNER: MD


Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated - July 2016

BAF Ref Number

Principle Risk



of the objective?


controls where no


BAF (9) SO (3)Paper to Finance &

Resouces CommitteeT Sep-15

SO (1)Internal Audit report -

limited assurance Ind Apr-15%

KPIs for IM&T reported to

IM&T Committee quarterly T

Update on IMT Strategy

presented to Jun FRC T Jun-16

IM&T Committee minutes

standing item on FRC

agendaT Mar-16

SO (8)

Engagement of consultancy to

support development of

strategy

IM&T Board /

TEG / Board

Session with Trust Board

in May 2015 involving

presentation by

consultants

T May-15

Focus on IM&T operations

and management within 15/16

Internal Audit Plan

IM&T Board /

Risk & Audit

Committee

IT Helpdesk Internal Audit

Ind Oct-15

% recommendations made

within internal audit report

Action plan in

place

CO

O

IT Support Performance

report presneted to FRCT Jun-16

Remote Working

Ind Jan-16

% Limited assurance re Trust

making optimal use of IT

for remote working

Action plan in

place

CO

O

Cross Ref

Ref # of

entry on

corporate

risk

register

Action to meet

gaps

Action plans (or

reference to action

plans) to meet

gaps in control or

assurance

What monitoring

arrangements

are in place?

By w

hen

Le

ad

Gaps in control or

assuranceRisk Controls Assurance

Receiv

ed

Link to

Strategic

Objective

How does

this risk

link to the

Trust's

objectives

and

priorities?

Assu

ran

ce R

atin

g (In

d)

Internal

monitoring

recommendations made

within internal audit report






Tru

st (T

) or In

dependent (In

d)

TEG / Finance

& Resources

Committee

Evidence that shows risks

are being managed and

objective being delivered

Co

ntro

l ratin

g

CO

O

BAF RISKS

Action plan in

place

IM&T Board and operational

group established to oversee

and be responsible for

agreement of strategy

R794

R857

Failure to ensure that the

required IT infrastructure

and strategy is in place

impacts on the Trust's

ability to deliver services,

improve quality and

transform services.

RISK OWNER: COO



BAF Ref Number

Principle Risk


gapsB

y w

hen

Le

ad

Gaps in control or


Link to

Strategic

Objective

Internal

monitoring

BAF (9)Information Governance

Arrangements in Place

IG Committee /

FRC

IG Toolkit Submission T Mar-16


Significant AssuranceInd Mar-16

EDMS project in place IM&T Board Presentation to BoardT Jan-16

Learning from implementation

of major IT systems

IM&T Board Report presented to April

Risk & Audit Committee T Apr-16

discussion identified lack of

formal process for post

implementation reviews

following major capital

action for RAC AD

CA

Sep

-16

IM&T Board /

CIT

IM&T Capital Plan and

Future Risks paperT Jan-16

FRC Update on IMT Strategy

including broader level

assessment presented to

Jun FRC

T Jun-16

Additional capital funding

not yet identified.

Business case to

be developed CO

O

Oct-1

6

Recruitment of substantive

CIO in progress - appointment

made / start date Aug 2016

Executive Team Updates on recruitment

process given to Board

Noms Ctte. Start date

agreed (Aug 2016)

T Apr-16

Strategic Oversight of key

areas of IM&T development

considered by IM&T Board

IM&T Board minutes presented to FRC

T Jun-16

Work underway with Sheffield

health and social care

community on Digital

Footprint, with assessment

undertaken on Trust score on

Digital Maturity Index

IM&T Board Assessment on Trust

score on Digital Maturity

Index

T ?

fro

m a

mb

er

-

july

2016

Failure to ensure that the

required IT infrastructure

and strategy is in place

impacts on the Trust's

ability to deliver services,

improve quality and

transform services.

Interim CIO review of priorities

& financial assessments to

feed into capital planning - 3

year plan agreed



BAF Ref Number

Principle Risk


gapsB

y w

hen

Le

ad

Gaps in control or


Link to

Strategic

Objective

Internal

monitoring

BAF (10) SO (7)

Capital funding allocation

within financial plan

CIT / Trust

Board

Paper outlining process

taken by CIT to allocate

Capital resources as part

of 15/16 annual planning

process

T

May-15

Risk identified re

underestimate of funding

for IM&T new build

requirements

Split of costs to be

allocated across

new build / general

contingency funds

CF

O

actio

ne

d

Capital

Investement

Team / FRC

2016/17 Capital

Programme allocation /

risk assessment shared

with FRC

T

Mar-16

TEG approved additional

funding with revised project

management arrangements to

support expenditure plans

IM&T Board TEG minutes T

Hospital Redevelopment

Project management

arrangements in place

Hospital

Development

Project Board

limited assurance report:

Financial Management &

Project Planning - New

Build Project

Ind Feb-15

% recommendations

identified within internal

audit report

action plan against

recommendations CF

O

actio

ne

d

Project implementation group

set up to manage transfer of

activity into New Build -

reporting into Project Board

Hospital

Development

Project Board

Reports into Project Board

T Jun-16

Employment of Cost

consultantsHospital

Development

Project Board

Monthly hospital

development updates to

Trust Board and F&RCT Mar-16

Enhanced Governance

Arrangements for Hospital

Development

Hospital

Development

Project Board

Non-executive monitoring

of project plans against

delivery at project board T Sep-15

Delays to New Build

project issued by main

building contractor

(Simons)

Additional

Mitigations:

Monthly hospital


Trust Board and F&RCT Jun-16

CFO sign off project

amendments >£25kT

* Exec level

discussion to

ensure delivery of

project

R867

R916

Failure to deliver major

capital projects to budget

and on time impacts on the

rest of capital programme

and causes operational

disruption and/or poor

patient experience.

RISK OWNER: CFO



BAF Ref Number

Principle Risk


gapsB

y w

hen

Le

ad

Gaps in control or


Link to

Strategic

Objective

Internal

monitoring

Contingency arrangements in

place Built into contract and

contingency position

reported to Project Board

T Jun-16

* Management of

the project

contingency

Design and Build contract

locked in place with risk

transferred to contractor

Project monitoring versus

contract with challenge to

all project delays

T Jun-16 * Internally

phased delivery

plans for activity

CF

O

On

go

ing

Realistic revised work

programme fully accepted

by Project Team (less risk

of unforeseen events)

T Jun-16

BAF (11) SO (1)

Dec-15

SO (8)

Review of capacity

(bed numbers)

pending new build

to feed into TEG

and agree actions

CO

O

fro

m g

reen

- j

uly

2016

Activity plans

revised and O/P

commissioning

project group

established to

manage transfer of

actvity into new

building

Capacity constraints impact

on our ability to deliver

planned activity and

manage demand impacting

on operational efficiency,

service quality and financial

performance.

RISK OWNER: COO

* Focus on cash

generation via

estate

rationalisation,

working capital

management and

a new loan

application

(approved).

Monthly hospital


Trust Board and F&RC

New Build Programme Hospital

Development

Project Board /

Finance &

Resources

Committee /

Trust Board

Delay in New Build

completion - risk to delivery

of outpatient activity plans

T R770

R828

R842

R900

R904

R905

R922

CO

O

Oct-1

6



BAF Ref Number

Principle Risk


gapsB

y w

hen

Le

ad

Gaps in control or


Link to

Strategic

Objective

Internal

monitoring

BAF (11)

Progress being made to

embed workforce planning

into business planning cycle

Finance &

Resources

Committee /

Trust Board /

TEG

Strategic Workforce

Planning paper identified

key workforce challenges

affecting the Trust's

clinical divisions

T Feb-15 Need to bring progress

update back to Board for

discussion

SEE BAF 4

DH

R

Retirement planning audit

undertaken

Finance &

Resources

Committee

Paper to Finance &

Resources Committee

T Sep-15

Recruitment of additional

consultant capacity / to fill

vacancies

TEG Successful recruitment to

a number of consultant

posts

T ? Inability to recruit within

specific specialties eg

neurodisabilty

Commissioner

funded project in

place to review

models of care for

neurodisability

CO

O

Mental Health and Critical

CareReviewing

'package' where

recruitment is

difficult

MD

Nursing recruitment TEG / Board Over recruitment of nurses

in May 2016 to account for

natural attrition / maternity

leave etc

T May-16

TEG Business planning paper

to TEG / Board

T Sep-15

Internal Audit on Business

Planning Processes -

significant assurance

Ind Apr-16

Sep-15

Outpatient Clinics @ Northern

General

In place T

Revised business planning

process designed to support

delivery of activity plans -

capacity investment decisions

to be taken at risk

Theatres expansion

Hospital

Development

Project Board /

FRC / Trust

Board

TCompleted

R770

R828

R842

R900

R904

R905

R922







performance.

RISK OWNER: COO



BAF Ref Number

Principle Risk


gapsB

y w

hen

Le

ad

Gaps in control or


Link to

Strategic

Objective

Internal

monitoring

BAF (11)

Use of external consultancy

support to increase

productivity in theatres and

outpatients

FRC / Trust

Board / TEG

Standing reports

(transformation &

efficiency) to Finance &

Resources Committee

T Dec-15

Targets set around efficiency

of recruitment processes

Quarterly Workforce

Information Reports T May-16

variation in performance

review being

undertaken

DH

R

Monthly workforce metrics

snap shot reports to F&RC T Dec-15

Internal Audit report

Ind May-15

Recommendations made

re KPIsImplementation of

recommendations

DH

R

BAF (12)

Regular monthly reporting to

Board in conjunction with

regular management reports

Board / Division

Performance

Reviews

Board Papers

T

Mar-16

Monitor Finance Ratings Ind May-16

Cash

Committee

ToR / Minutes

T

Mar-16

FRC

Mar-16

RISK OWNER: CFO Further loan application

submitetd to ITFF to provide

additional cover re capital

programme

Board In place

T

Mar-16

Performance management re

major projects

FRC Hospital Development

Project Board minutes TMar-16

CFO self assessment within

Monitor informal visit of Trust

controls judged against

Monitor criteria for Trusts in

turnaround / recovery (95% in

place)

CFO

T







performance.

RISK OWNER: COO

Newly formed cash

management committee -

enhanced governance control

re cash management with

particular focus on recovery of

Enhanced scrutiny re trades

payable and receivable

Cash

Committee

Cash Forcast with papers

to Cash CommitteeT

Failure to manage the Trust

cash position would result

in the Trust not being able

to satisfy its oblications in

respect of pay and non-pay

costs

FRC / Trust

Board / TEG


Number Risk Title Risk RegisterCurrent Risk

Score

Risk Level

ChangeBAF LINK

R687 Loss of Neurosurgical services to the Trust and resulting implications Corporate 15 ↔ 6 & 7

R726 Transformation Agenda Corporate 12 ↔ 2 & 3 & 5

R770 Pharmacy Weekend Service Divisional 12 ↔ 1 & 11

R794 IT Service – lack of capacity Corporate 12 ↔ 1 & 4 & 5 & 9

R828 Lack of ability to fill junior rotas - No action plan received Divisional 15 ↔ 1 & 3 & 4 & 11

R832 Backlog of completion of discharge summaries Corporate 12 ↓ 1 & 2 & 3

R842 Underperformance of activity and income Corporate 12 ↔ 1 & 2 & 11

R857 Licensing Novell - Threat of additional cost Corporate 20 ↔ 2 & 9

R867 New Build - Slippage in main programme dates - No action plan received Corporate 12 ↔ 1 & 2 & 10

R899Quality Management Staffing Resource - risk of insufficient resource leading to failure to comply with UKAS

standards assessment which will result in the Trust having unaccredited services Corporate 20 ↔ 1 & 3

R900Anatomical Pathology Technologists (APTs) shortages within mortuary services - risk of inability to provide a

safe post mortem service to Trust or service Divisional 20 NEW 1 & 4 & 7 & 11

R904 STH provision of additional capacity from April 16 as outlined in 16/17 capacity plan Corporate 12 NEW 1 & 11

R905 Waiting list for paediatric dentisty Divisional 16 ↑ 1 & 4 & 7 & 11

R911 Sustainable cash resources Corporate 15 NEW 12

R913 The absorbtion of six General Paediatric Doctors into the Secretariat Divisional 20 ↔ 1 & 2 & 3 & 4 & 8

R915 Risk of changing face to face interpretter services - No action plan received Corporate 12 NEW 1 & 3 & 7

R916Pressure on contingency funds due to escalating costs impact of increased project costs on funding

available for equipmentCorporate 16 NEW 1 & 10

R922 Staffing levels within theatres (nurses and ODPs) to accomondate 16/17 capacity plans Divisional 12 NEW 1 & 3 & 4 & 11

R925 Nurse staffing levels in inpatient areas - No action plan received Corporate 12 NEW 1 & 3 & 4

R927 Transition from childrens' to adult services Corporate 12 NEW 1 & 7

R823 Combined risks associated with New Build Project Corporate CLOSED 1 & 2 & 10

R846 IT Systems failure due to air conditioning problems Corporate CLOSED 1 & 2 & 16 & 9 & 10 & 11

R876Variance in 18 week PTL outpatient numbers and outpatient queue data - risk of incorrect management

leading to increased waiting times and breach of targetsDivisional CLOSED 1 & 2 & 3

R491 Failure to deliver capacity in Theatres due to lack of anaesthetists Divisional 9 ↓ 1 & 3 & 4

R694 Achievement of Diagnostic 6 week waiting time target Corporate 8 ↓ 1 & 2

Risk Register Key - All Open Risks mapped to Strategic Objectives with a risk score > 12

Closed Risks since last quarter

Risks with scores reduced to below 12 since last quarter

Number Risk Title Risk RegisterCurrent Risk

Score

Risk Level

ChangeBAF LINK

R881 Lack of specialist trainees impacting on the ability to provide 24/7 service continuity Divisional 9 ↓ 1 & 4 & 11

R896 Threat of junior doctors industrial action Corporate 8 ↓ 1 & 6 & 11

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