REPORT TO TRUST BOARD
Date: 9 December 2015
Agenda No: 9.3
Date Paper produced:
Paper Title: Trust-wide Risk Register, Corporate Risk Register and Board
Assurance Framework
16 November 2015
Sponsoring Director
(responsible for signing
off report):
Helen Astle, Director of Quality Assurance and Governance
Author:
Moya Berry, Head of Compliance and Regulation
Helen Astle, Director of Quality Assurance and Governance
Purpose/Decision
required:
This report provides an update of progress as at the 16 November 2015 to the Trust
Board on the Corporate Risk Register and development in relation to Risk
Management.
Impact on Patient
Experience:
The Corporate Risk Register will help ensure the Trust’s governance structure and
processes are robust which will contribute to providing high quality, safe and effective
care for patients, carers and members of the public.
Impact on Financial
Improvement
History: (which groups
have previously
considered this report)
None
 It should be noted that the Risk Register and the Board Assurance Framework
(BAF) are dynamic documents and are constantly being reviewed and updated by
risk owners. The risk register is current at the time of drafting the report but
potentially will have been updated by the time of the meeting itself.
 Risks are reviewed by the Risk Assurance and Policy Group every month (last
reviewed on the 23 November 2015), every 2 months by the Audit Committee
(last reviewed on the 16 November 2015) and bi-monthly by the Trust Board (last
reviewed on the 11 November 2015).
 The Quality & Oversight EMB last discussed the Risk Registers on the 12
November 2015
Key Issues for discussion
The Trust Board is requested to note the Corporate Risk register and the current
development work to improve Risk Management within the Trust
Related Corporate Objective:
Corporate Objectives: Links to corporate objectives to improve quality and manage resources.
Related CQC 5 Key Areas
of Care:
x
x
x
Safe
Responsive
x
x
Effective
Caring
Well-Led
1
Has an equality impact assessment form been completed?
If not applicable, Please state why not applicable.
Has legal advice been taken?
No
No
Does this report have any financial implication?
This depends on the specific risks identified
on the Corporate Risk Register. Any financial
implications will be addressed through the
mitigating actions which may include
supporting business cases.
If so, has the report been approved by the Financial Department? n/a
2
Executive Summary
1. Trust’s Risk Register

The source data for the Trust Risk Register and Corporate Risk Register was extracted from Datix on
16 November 2015. Information is made up of all risks held the Clinical and Corporate Directorate risk
registers.

Currently there are a total of 338 risks held on the Trust’s Risk Register; no change from the previous month.
There are 189 risks which are overdue for review (56%). This number has increased by 8% points since
October 2015.

A remedial process is being put in place, whereby the Compliance and Regulation team are meeting with
leads to review and update the Directorate risks and establish timescales to address overdue risks. This
process will be facilitated more easily once the Clinical Governance Facilitators are in post.
2. Corporate Risk Register


The Corporate Risk Register comprises of those risks rated 15 and above
Currently there are a total of 30 risks on the Corporate Risk Register
The Corporate Risk Register is presented as Attachment 1
2.1 The highest rated risks on the Corporate Risk Register (rated 20 and above)
There are 2 approved risks rated 20 these are set out in the table below
Risk ID
Description
1373
Finance: Failure to have sufficient cash flow to meet operational
requirements
1376
Action update (Dec 2015)
The financial forecast for the Trust has increased; As a result a submission
has been made from the Trust to the Independent Trusts Financing Facility to
request additional funding. Update
Finance: - Failure to demonstrate financially and clinically sustainable plans
Risk on the
Board
Assurance
Framework
Yes
Yes
Risk Rating
November
2015
20
20
Action update (Dec 2015)
To Increase level of Expenditure controls on Pay and Non Pay.
Complete the development of robust activity and capacity modelling as part
of business planning strategy.
3
2.2 Risks escalated up to the Corporate Risk Register
Risk
Title
Date
entered
onto the
risk
register
Date of
last review
Directorate
Description
Reason for increase
1373
Failure to
have
sufficient
cash flow to
meet
operational
requirements
01.04.14
30.10.15
Finance
Directorate
Finance: Failure to
have sufficient cash
flow to meet
operational
requirements
To ensure
that CHS
Child Health
Information
System (CHI
system)
meets the
contracted
specification
20.06.14
The financial forecast
for the Trust has
increased, As a result
a submission has
been made from the
Trust to the
Independent Trusts
Financing Facility to
request more funding
Child Health
Information System
(CHIS) Action plan
targets not being met.
1345
12.11.15
Previous
risk rating
Risk
ID
Integrated
Women's,
Children's,
and Sexual
Health
Directorate
The Trust is
commissioned to
provide a Child
Health Information
Service, which
includes an IT
system (CHIS) All
providers which
includes an
electronic data
linkage with GP and
maternity clinical
systems and other
child health
information
systems. This will
identify children
who are not known
to health visiting
services in their
resident borough.
The Trust is
required to procure
a CHIS IT system in
line with a national
specification in
14/15.
Action –
update(Dec 2015)
Community IT
strategy process
being developed to
transfer EPEX to
the new Electronic
Patient Record
system in March
2016. CHIS action
plan is submitted
monthly to the
Directorate Quality
Board and
Externally
to NHS England as
part of the Early
years CQUIN.
15
Risk rating
November
2015
Between 22/10/2015 and 16/11/2015 2 approved risks have been escalated up to the Corporate Risk Register
20
Although CHIS
project team is in
place to address the
action plan. Action
plan targets are not
being achieved as the
community EPEX
system is still in
current use.
12
15
4
2.3 Risks de-escalated from the Corporate Risk Register
1523
Risk
Title
Date
entered
onto the
risk
register
Date of
last review
Directorate
& Service
Description
Reason for
Decrease
Failure to
comply with
London
Quality
standards
(Paeds
emergency
surgery)
resulting in
inadequate
treatment
of patients.
08.06.15
26.10.15
Corporate
Medical
Compliance with
LQS is a
challenge in
paediatrics as with
other London
Trusts. This limits
access to senior
clinician expertise
and intervention
24/7 and may
result in longer
LOS and delayed
decision making.
Action –
update(Dec 2015)
Previous
risk Rating
Risk
ID
Update reported
to Clinical
Quality Review
in November
2015:
Business plans
and service
transformation
projects are in
place across
Family Services:
Paed
Assessment
Unit
Internal
Professional
standards are
being met
across
Paediatrics
There is an
Increase in
paediatric
establishment
Risk rating
November
2015
There has been 1 risk de-escalated from the Corporate Risk Register
20
12
2.4 Breakdown of Red Risks by Directorate
Integrated Adult Care
Risk
ID
1338
Description
1443
Inadequate CQC report for nursing home who are
commissioned by the CQC to provide intermediate
beds
Digi pens that have been purchased for the
community are not compatible with EPEX
Trust does not have a named safeguarding nurse to
roll out training etc.
Podiatrists are taking calls for the district nurses
Difficulty in recruiting to occupational therapy
1423
1147
1521
1505
Inadequate piped medical gases on Duppas 1&2
Date Risk placed
onto the Register
June 2014
Current
Risk rating
16
Target Risk
Rating
4
April 2015
15
4
March 2015
15
2
March 2015
15
2
June 2015
May 2015
15
15
2
3
5
Integrated Women, Children’s and Sexual Health
Risk
ID
1534
Description
1101
Long waits for assessments for diagnosis of autism
1184
Antenatal screening standards – 20-25% of women at
CHS receive full screening tests at first antenatal
appointments
CHS child health information services does not meet
national specifications
1345
No access to medical records in community
paediatrics
Date Risk placed
onto the Register
June
2015
Current
Risk rating
15
Target Risk
Rating
4
Dec
2012
June
2015
15
4
16
9
June
2014
15
4
Integrated Surgey,Cancer and Clinical Support
Risk
ID
1592
Description
1588
Delay in radiology report turnaround times
1600
In Health MRI contract not signed since 2009
DRSS screening at 13.5 months
Date Risk placed
onto the Register
Sept
2015
Sept
2015
Aug
2015
Current
Risk rating
15
Date Risk placed
onto the Register
Oct
2012
Current
Risk rating
15
Target Risk
Rating
6
15
9
15
5
Medical
Description
1095
Inadequate job planning for consultants
1522
Reliability and capacity of diabetes service
June
2015
16
Target Risk
Rating
4
4
Nursing
Risk
ID
728
Description
National Inpatient survey reflects low patient
experience
Failure to provide patients with a good experience
1563
1052
1587
A lack of robust systems to protect patients against
infections
Infusion pumps not compatible with CRS
millennium
Date Risk placed
onto the Register
April
2014
July
2015
Sept
2012
Aug
2015
Current
Risk rating
16
Target Risk
Rating
8
15
6
16
8
16
Human
Resources
Risk
ID
1566
Description
642
Recruitment and retention
691
Gaps in compliance with core skills training
Ineffective management and leadership
Date Risk placed
onto the Register
July
2015
Current
Risk rating
15
Target Risk
Rating
2
May
2012
15
12
April 2014
15
4
Finance
Risk
ID
1374
Description
1376
Failure to demonstrate financially and clinically
sustainable plans
Insufficient cash flow
1373
Failure to meet TDA approved total
Date Risk placed
onto the Register
April 2015
Current
Risk rating
15
Target Risk
Rating
10
April 2015
20
15
April 2015
20
5
6
Informatics
Risk
ID
1142
1508
1432
Description
Alert organisms surveillance package does not
have the same capacity and capability as ICNet and
therefore infection control are not aware of patients
who have infections
Reports for OPD and 18 week targets
Dementia report screen error. Scores for the
dementia screening is out of 10 but on Cerner the
score is aligned to the Mini Mental Screening
Examination (MMSE) which scores out of 30
Date Risk placed
onto the Register
Feb 2013
Current
Risk Rating
15
Target Risk
Rating
12
May 2015
20
20
April 2015
15
1
Performance
Risk
ID
Description
1568
Failure to achieve performance standards
Date Risk placed
onto the Register
July 2015
Current
Risk rating
16
Target Risk
Rating
4
Governance
Risk
ID
1564
Description
Noncompliance with CQC regulation standards
Date Risk placed
onto the Register
July 2015
Current
Risk rating
15
Target Risk
Rating
4
2.5 Risk Management Workstream

The Risk Management Strategy and the Risk Assessment Process is currently under review, and it is the
intention to develop a comprehensive Risk Framework. This work will include strengthening the process on
how risks are reported and managed. This work will tie in with the development of a Trust Assurance Map.
Risk Management Training

The E-learning module is under review and also bespoke training will be provided for the Directorate
governance facilitators as they come into post.
Board Assurance Framework (BAF)



The Board Assurance Framework is currently under review and a revised template has been developed to
provide assurance that the Trusts key strategic objectives are being met.
Currently meetings are being held with the executive leads to review and refresh the principal risks linked to
the strategic objectives.
Each principal risk will have an executive lead and a nominated management lead that will be required to
provide an update each month for the Trust Board.
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