Item 8
Board Assurance Framework (BAF) and Corporate
Risk Register update Q3 & Q4 2013/14 and Q1 & Q2 2014/15
Produced by:
Ian Tombleson, Director of Corporate Governance
Board of Directors Meeting
4 September 2014
Action for Board:

For information


For consideration


For decision
1
Update of the BAF & Corporate Risk Register
1.
Introduction
This is a review of the corporate risk register with a limited review of the BAF for the
preceding four quarters – Q3 and Q4 of 2013/14, and Q1 and Q2 of 2014/15. As a
result of the timing of this paper (that is post summer), this has undergone partial
review by the Management Executive but more is required. Therefore a fuller review
of the BAF will come in November which will include a review of the second quarter.
Review will then return to its normal timescales of quarterly/six monthly.
2.
Analysis
In terms of this update the usual process has been followed to a point. Management
Executive views have been sought and some has been received, but a full review of
has not yet been undertaken. However the revisions that have been made are
worthy of analysis/comment.
The risk register (Appendix A) consists of three main section, the general corporate
section covering the major risks that face the organisation trust-wide, on an on-going
basis, the high level operational risks and a third section (not present in this update)
that reflects the risks to the delivery of the corporate priorities (which are present in
the operational plan). This third section will be once the first review of progress of the
strategic priorities has been completed. Appendix B is for reference and contains the
scoring methodology.
The register as whole contains 41 risks with the following breakdown:
Risk profile at current review
Risk profile at previous review (Sep 2013)
6 Yellow = Low/Moderate
9 Yellow = Low/Moderate
33 Amber = Moderate/High Risk
27 Amber = Moderate/High Risk
2 Red = Very High Risk
1 Red = Very High Risk
Total = 41 risks
Total = 37 risks
Analysis indicates the number of risks are increasing and their profile is tending
towards increasing risk.
2
Taking the corporate part of the register section by section:
Statutory/legal
The number of risk continues to be 2 and the risk ratings remain the same.
Regulatory
This contains 2 risks, a third about Dubai has been transferred to the Dubai
section of the register. Because of the current situation with RTT18 the
potential to breach the conditions of the Monitor licence has increased;
although as would be expected a more rapid return to normal performance will
mitigate this. This is reflected in an increase score in the risk about the
Monitor licence.
Major incidents
This contains 2 risks (as did the previous version of the register) both rated at
the same level.
Quality
This section continues to include 5 risks. 2 risks are scored at an improved
lower level, mandatory training levels and failing to identify poor standards;
the other three remain at the same level.
Financial
This section continues to include 2 risks. Risk 12 is now focussed on the
Trust’s ability to maintain financial surplus and is rated as an amber risk.
Staff
This section contains 1 risk (the same as previously) and is rated at the same
level (amber).
Operation of the Trust’s network (renamed)
This section now contains 4 risks (as opposed to 2 previously). The two new
risks focus on preparation for the new build and are both amber rated.
Research
This section contains 1 risk, related to a potential to breach regulations and
rated at the same level post MHRA inspection.
Teaching and training
This section continues to contain one risk about MPET funding, rated as an
amber risk.
3
Environmental
This section continues to contain one risk about meeting the trust’s carbon
target and is rated as a yellow risk.
Political/strategic
This section continues to contain 3 risks rated at a moderate/high level which
are all rated at low probability but high impact and are probably at de minimis
levels.
Reputation
This risk remains at an amber level, no change from previous.
Commercial/pharmaceutical
As anticipated, given the current situation the on-going business risks for
pharma are substantially elevated with one red risk relating to the
consequences of the need to stop manufacture (whilst continuing to note that
this was not due to patient safety concerns).
Commercial/Dubai
This section now contains four risks (as opposed to three previously). The
additional risk has been transferred from the regulatory section and is
elevated. A poor outcome of the regulatory inspection in the new year is not
expected but inspection results always remain uncertain; the team in Dubai
are working closely with the Director of Clinical Quality and Safety to focus on
preparation.
Commercial/Private
There is one risk in this section about mainting/growing the business and it
remains relatively low (yellow, score 6).
Taking the operational section of the register:
This part of the register now contains 7 risks as opposed to the 5 previously. The
three new ones are all rated as amber (score 12) and appear because of the RTT18
& theatres situation and a risk that has become apparent because of successive
floods in the eye bank.
In terms of Board Assurance Framework
The BAF will be presented in full to the Board in November.
4
3.
Recommendations
The Board is invited to:





Note the analysis and changes to the risk register.
Note that the number of risks has increased by 4 and that the risk profile is
tending towards increasing risk (and the reasons for that).
Comment on the updated risk register.
Note that the Board Committees will continue to assure the Board in relation
to their respective oversight responsibilities for risk
A further update and the full BAF will come to Board in November.
Ian Tombleson
Director of Corporate Governance
30 August 2014
5