Attachment 10
TRUST BOARD – OPEN SESSION / Tuesday 13 January 2015
Subject / Corporate Risk Register
Prepared by / Steven Kibble, Head of Governance
Approved by / Gillian Hoskins, Associate Director for Governance and Patient Experience
Presented by / Rob Little, Director of Finance
Purpose
To advise the Board of the current entries and movements on the Corporate Risk Register / Discussion /
Approval
Information /
Other
Trust Objectives
Safety / Quality / Efficiency / Workforce / Finance / Governance
/ / / / /
Executive Summary
The Corporate Risk Register has been updated following the Risk Management Committee (RMC) held on Tuesday 4 December 2014 and refreshed with risk handlers following the Audit and Assurance Committee Meeting held on Wednesday 10 December 2014.
a) 11 new risks had been escalated to the Corporate Risk Register following review by the Risk Management Committee of all Risk Registers. These Registers have also been informed by a programme of mock Care Quality Commission (CQC) Inspections – begun in November 2014.
Ref / Risk Title / L / C / Score
Corp 62 / Nurse staffing and agency usage / 3 / 4 / 12
Corp 63 / Limited mortality review / 4 / 3 / 12
Corp 66 / Administration process within the Trust / 5 / 3 / 15
Corp 67 / Planning for discharges / 4 / 3 / 12
Corp 69 / Lack of clarity regarding mental health pathways / 3 / 4 / 12
Corp 71 / Issues with provisions of medicines via homecare companies / 5 / 3 / 15
Corp 72 / Implementation of replacement PAS and migration from BT data centre / 4 / 4 / 16
Corp 73 / Statutory and mandatory compliance within Estates and Facilities / 4 / 4 / 16
Corp 74 / Level of income secured is not as contracted and budgeted for / 3 / 5 / 15
Corp 75 / Management of patients on Highcare / 4 / 4 / 16
Corp 76 / Pathology workforce destabilisation / 4 / 4 / 16
b) Increase in risk score since last meeting:
Ref / Risk Title / L / C / Score (Old) / L / C / Score (New
Corp09 / Failure to achieve CQUIN schemes resulting in financial penalty and reduction in the quality of care / 3 / 3 / 9 / 3 / 4 / 12
Corp10 / Patient safety compromised by lack of medical staff across the organisation / 4 / 4 / 16 / 4 / 5 / 20
Corp22 / Failure to achieve key performance indicators in relation to ED 4 hour performance, Cancer, Referral to Treatment Targets and VTE / 3 / 4 / 12 / 4 / 4 / 16
c) Decrease in risk score since last meeting:
Ref / Risk Title / L / C / Score (Old) / L / C / Score (New
Corp39 / Lack of overarching business continuity policy and plan. / 4 / 4 / 16 / 3 / 4 / 12
Corp51 / Pressure ulcers / 5 / 3 / 15 / 4 / 3 / 12
d) Risks closed:
Corp56 / Aseptic unit on Oncology not fit for purpose. / 3 / 4 / 12 / 2 / 4 / 8
e) Trust’s red risks not escalated to Corporate Risk Register
· M07 (Risk of harm to patients from inappropriate use of anticoagulants) Risk scored 4L x 4C. RMC asked for the scoring to be reviewed as it was felt there was adequate assurance that the likelihood was scored to high.
· Safeguarding Risk Register was received as draft and risk scores will be reviewed at the next Safeguarding Committee.
· FIN12 (Financial impact of service transfers) Risk scored 5L x 3C. Assurance was given that risk has been mitigated by actions and this will be reflected when the scoring is reviewed.
· PCD95 (Missed radiology reporting targets) Risk scored 5L x 5C. RMC asked for score to be reviewed as it felt mitigating actions was not reflected in current score. Division to review risk with Executive Medical Director and report back to RMC.
· PCD100 (Oncology staffing – Consultant) Risk scored 4L x 4C. RMC requested the score to be reviewed as it felt the risk had been scored to high for the current risk to the Trust.
Key Recommendations
The Board is asked to receive the latest Corporate Risk Register for discussion.
Assurance Framework
The Corporate Risk Register is an integral part of the Board Assurance Framework.
Next Steps
The Corporate Risk Register will be updated following review by the Risk Management Committee in February 2015.
Corporate Impact Assessment
NHS Values / Commitment to Quality of Care, Working Together for Patients, Respect and Dignity
CQC Regulations / All CQC Outcomes, but particularly Outcome 16
Financial Implications / None specific – identified where necessary
Legal Implications / None specific – identified where necessary
Equality & Diversity / All actions identified are intended to ensure the ongoing respect of equality and diversity of patients and staff
Performance Management / None specific – identified where necessary
Communication / N/A
Acronyms / Terms used in Report
(include all acronyms used in the report attached to the cover sheet)
EMG / Executive Management Group
RMC / Risk Management Committee
CQC / Care Quality Commission
6 January 2015
K:\Board Papers\Board Papers 2015\13 January 2015\Open\Agenda Item 969 15 Corporate Risk Register Cover Sheet.docx