Board Risk Profile Item 10

OPEN BOARD OF DIRECTORS
3rd September 2014
Open BoD: 03.09.14
Item:
10
TITLE OF PAPER
Board Risk Profile
TO BE PRESENTED BY
Rosie McHugh, Director of Organisation Development/Board Secretary
ACTION REQUIRED
Discuss and approve the Board Risk Profile
Agree to continue to receive monthly updates
OUTCOME
To ensure the Board of Directors is fully informed of the high level risks that
are prevalent within the Trust
TIMETABLE FOR
DECISION
The Risk Profile will be presented to the Board of Directors on a monthly basis
BAF OBJECTIVE No
and TITLE
2.2
2.3
2.4
3.4
6.2
6.3
LINKS TO OTHER KEY
REPORTS / DECISIONS
Internal Audit Reports on Risk Management.
Corporate Risk Register
Board Assurance Framework
LINKS TO OTHER
RELEVANT
FRAMEWORKS
BAF, RISK, OUTCOMES
ETC
Board Assurance Framework links to strategic objectives, corporate
(organisational) risk register, directorate risk registers.
Monitor’s Provider Licence
Monitor’s Risk Assessment Framework
Monitor’s Quality Governance Framework
IMPLICATIONS FOR
SERVICE DELIVERY
AND FINANCIAL
IMPACT
Implications of individual risks outlined on the Risk Profile
CONSIDERATION OF
LEGAL ISSUES
Compliance with Monitor’s Provider Licence and Risk assessment Framework.
Author of Report
Designation
Date of Report
Tania Baxter
Head of Integrated Governance
18th August 2014
QIPP programme not delivering financial savings
QIPP programme not delivering quality improvements
Negative impact on staff morale
Financial risk relating to Clustering
Workforce not responsive/flexible to user choice & needs
Reduction in income from SDS
BRP Sept 14 Page 1 of 8
BRP Sept 14 Page 2 of 8
SUMMARY REPORT
Open BoD: 03.09.14
Item:
10
Report to:
Open Board of Directors
Date:
3rd September 2014
Subject:
Board Risk Profile
From:
Rosie McHugh, Director of Organisation Development/Board Secretary
Prepared by:
Tania Baxter, Head of Integrated Governance
1.
Purpose
The attached report is the Board Risk Profile produced using the high level risks currently recorded
on the Trust’s Corporate Risk Register. This report is provided to enable greater awareness and
understanding at Board level of the major risks facing the organisation and for the Board to
challenge the effectiveness of the controls in place to mitigate these risks.
2.
Summary
The corporate risk register records the risks that underlie the strategic, overarching risks that are
captured on the Board Assurance Framework (BAF); the operational risks that the Trust faces on a
day-to-day basis. Risks that cannot be controlled within a single directorate, or that affect more
than one directorate, are recorded on the corporate risk register.
The Board Risk Profile contains all ‘amber’ and ‘red’ rated risks that are recorded on the corporate
risk register, after controls have been put in place to manage them.
The risks on the Risk Profile have been scored using the risk rating matrix below.
Consequence
Rare
(1)
Unlikely
(2)
Likelihood
Possible
(3)
Likely
(4)
Almost
certain
(5)
Negligible
Minor
(1)
(2)
1
2
3
4
5
2
4
6
8
10
Moderate
(3)
3
6
9
12
15
Major
(4)
4
8
12
16
20
Catastrophic
(5)
5
10
15
20
25
There are currently 7 risks on the Board Risk Profile.
Since last month’s report, the following amendments have been made:
Risk No. 2175 (CIPs) – the shortfall highlighted in the risk description has been amended to reflect
latest financial reports
Risk No. 2180 (APMS contract) – the date for the manager backfill has been amended to September
2014
Risk No. 2294 (LDS contract) – management actions have been updated
Risk No. 2383 (Brierley Medical Centre) – new risk added to the profile
All other risks have been reviewed and remain the same.
BRP Sept 14 Page 3 of 8
3.
Next Steps




4.
The Trust’s Risk Department will continue to maintain the corporate risk register on the
Board’s behalf;
‘Red’ and ‘amber’ risks from the corporate risk register will be presented to the Board of
Directors, on a monthly basis, via the Risk Profile;
The Executive Directors’ Group (EDG) will review the Risk Profile prior to Board meetings;
The Corporate Risk Register will continue to be presented to the Quality Assurance
Committee and Audit and Assurance Committee on a quarterly basis.
Required Actions
The Board of Directors is asked to:


5.
discuss and approve the Board Risk Profile;
agree to continue to receive monthly updates.
Monitoring Arrangements
The corporate risk register will be maintained by the Trust’s Risk Department. The Board of Directors
will receive and monitor high level risks on a monthly basis. EDG, the Quality Assurance Committee
and the Audit and Assurance Committee will receive and review the corporate risk register on a
quarterly basis.
6.
Contact Details
For further information, please contact:



Tania Baxter, Head of Integrated Governance
2263279
[email protected]
BRP Sept 14 Page 4 of 8
Board Risk Profile September 2014
Risk No
BAF No
Date
Entered
Risk Ratings
Lead Director
Summary of Risk
Orig Last Current
L C
Comparison to
Last Report
Controls in Place
Work to continue to further
develop cluster-based tariff.
Sept 14
Joint sub-committee in place between SHSC
and NHSS CCG with annual action plan
agreed.
SHSC and NHSS CCG to
review progress made on tariff
development and agree
activity/payment mechanisms
that will apply for the period
1st Oct 2014 to 31st Mar
2015.
Sept 14
Ongoing work to ensure that
all relevant service users are
allocated to clusters and
reviewed as necessary.
Mar 15
Clinical audit of cluster
allocation to be commenced to
help improve quality.
Nov 14
Memorandum of Understanding in place
between SHSC and commissioners.
BAF:
3.4
Monthly reporting of cluster tariff.
Deputy Chief
Executive
Risk of financial loss due to future
contracts being procured on the
basis of Mental Health Clustering.
12
12
12
3
4

Robust clinical activity recording to inform
costings.
Contract Management Group monitors
contract activity.
16.06.12
Protocol for cluster allocation agreed.
Training in place for clinicians.
Additional non-recurrent funding in place until
Sept 14 to ensure tariff work is completed on
time.
Clustering dashboard developed enabling
quality of cluster allocation to be monitored by
team managers, directorate leads and project
manager. Results to be reported to Project
Board.
Key:
Orig = Original risk score when risk was entered onto the register
Last = Risk score for the previous month’s report
Current = Current risk score
L = Likelihood of risk occurring
C = Consequence of risk
BRP Sept 14 Page 5 of 8
Date
Project Board established which monitors the
implementation of Mental Health Clustering.
Clusters to be used for monitoring contract in
2014/15 but underpinned by block contract
payment.
2161
Management Action
Risk No.
BAF No.
Date
Entered
Risk Ratings
Lead Director
Summary of Risk
Orig Last
Current
L C
Comparison to
Last Report
E-rostering system in operation.
2206
BAF:
1.1
4.1
7.5
Controls in Place
Director of
Human
Resources
Risk to quality of care as a
result of staff working excessive
hours and exceeding Trust
guidelines and policy.
Management Action
Date
Gaps in control need to be
identified and addressed.
June 14
HR Director to ensure
compliance with internal audit
recommendations.
August 14
Engagement with tender
process and framework
agreements.
Completed
Clinical Nurse Manager appointed
15
12
12
4
3

Task and Finish group established
26.11.13
Executive Level Discussions taking place.
LD Staffing Services Project Group
established.
2294
BAF:
2.2
2.3
2.4
Director of
Finance
Chief Operating
Officer/Chief
Nurse
Risk of potential non-renewal of
contract for Learning Disability
(LD) Services which could
result in non-recurrent cost in
relation to termination benefits.
Business Planning Group.
12
12
12
3
4

Executive Directors’ Group.
Finance & Investment Committee.
13.02.14
2180
BAF:
2.1
3.3
22.07.13
Deputy Chief
Executive
Director of
Commercial
Relations
Risk of potential non-renewal of
contract for provision of APMS
(Alternative Provider Medical
Services) through the Clover
Group Practice from 31 March
2014. Deferred with an agreed
extension to existing
arrangements until 30th
September 14.
Relationships with NHS England being
developed due to change of contractual
relationships and responsibilities.
Business Planning Group (BPG) and Finance
and Investment Committee (FIC) oversee
contractual issues.
Progress reported and monitored via
Executive Directors Group to Board.
12
12
12
3
4

BRP Sept 14 Page 6 of 8
Explore partnerships to bid to
retain/enhance market share.
Agree strategy to reduce risk
of non-recurrent cost with
SCC.
Dec 14
(Next due)
Assess likely impact and build
into future financial planning.
Completed
Additional Band 8a to be
recruited.
Regular progress reports to be
provided to BPG and FIC
April to Sept
14
Working relationships to
continue to be nurtured with
NHS England.
Ongoing
Clover Group’s Service
manager to work on primary
care strategic development
and lead on tender exercise
July 14
Additional Manager to be
recruited to backfill service
manager across Clover Group
Practices.
Sept 14
Meridian Productivity
consultancy firm working with
Clover Group
June 14
Risk No.
BAF No.
Date Entered
Risk Ratings
Lead Director
Summary of Risk
Orig Last
Comparison to
Last Report
Current
Controls in Place
Date
Consultant Nurse overseeing quality of care
provision.
Continue with recruitment until
all vacant posts filled.
October 14
Staff supervision timetable implemented.
Further development of inhouse training programme.
October 14
Replace and increase levels of
equipment on cottages to aid
staff in their work e.g. hoists,
wheelchairs.
October 14
Discussion with
commissioners to commence.
October 14
Engage with tender process
and framework agreements.
Feb 14
Explore partnerships to bid to
retain/enhance market share.
Sept 14
Agree strategy to reduce risk
of non-recurrent cost with
SCC.
Sept 14
Assess likely impact and build
into future financial planning.
Quarterly review of all CIP
plans and to explore
alternatives for consideration.
Sept 14
Service reconfigurations to be
monitored on regular basis
and presented to Board
quarterly.
Sep 14
(Next due)
Actions to address forecast
overspends is being
undertaken with directorates
as and where necessary.
Sep14
(Next due)
Standards regarding overseeing handovers
established and communicated.
2318
BAF:
1.1
Management Action
L C
Chief Operating
Officer/Chief
Nurse
28.03.14
Risk to service user safety and
quality of care provision as a
result of inadequate staffing
levels and skill mix, supervision
and leadership and inconducive
environment to manage client
demands at Woodland View
Nursing Home.
New system of observations in place.
12
12
12
4
3

Review of medication administration systems
underway.
Dementia staff training programme piloted.
‘Journal Club’ commenced; weekly brief staff
training / discussion sessions.
Recruited 3/4 Deputy Managers / Clinical
Educators.
Staffing to new agreed levels.
Executive Level Discussions taking place.
2310
BAF:
1.1
2.2
2.3
2.4
Director of
Human
Resources
Chief Operating
Officer/Chief
Nurse
LD Staffing Services Project Group
established.
Risk to quality of care and staff
morale due to the Local
Authority’s intention to retract
provider services
12
12
12
3
4

Business Planning Group discussing progress.
Finance & Investment Committee monitoring
position.
25.03.14
2175
BAF:
2.2
2.3
2.4
19.02.13
Director of
Finance
Chief Operating
Officer/Chief
Nurse
Joint QIPP plan agreed with Commissioners.
Accountability framework in operation. CIPs for
2014/2015 being managed and monitored by
Director of Finance. All Directorates have been
asked to present their detailed CIP plans
including development of three year CIP plans.
Inability to deliver required
financial savings for 2014/2015
including non- recurrent
achievement 2013/14 of £1.7m
CIP/ Contract Disinvestments.
The anticipated carried forward
shortfall on CIPs (financial
saving programme) as per the
July finance report for the year
ended 31st March 2015 is
£1,570k.
12
12
12
3
4

Forecast positions are being monitored with
directorates and where overspends are
predicted, work is undertaken to ensure
actions are in place to address.
MARs being utilised to enable
CIPs to be made recurrent in
2014/15.
BRP Sept 14 Page 7 of 8
Sep14
(Next due)
Risk No.
BAF No.
Date Entered
Risk Ratings
Lead Director
Summary of Risk
Orig Last
Comparison to
Last Report
Current
Controls in Place
BAF 1.1
19.08.14
Date
L C
Director of Commercial Relations overseeing
practice management
2383
Management Action
Director of
Commercial
Relations
Risk to service user safety and
quality of care provision as a
result of inadequate
management and systems at
Brierley Medical Centre and
Shafton Street Branch Surgery
by former service provider
Service Manager in situ providing leadership
and management to practices
N/A
N/A
12
3
4
NEW RISK ON
PROFILE
Nurse Practitioner working into the practices to
provide clinical leadership and establish
protocols
Development action plan in place following
CQC Warning Notices issued to former
provider
NHS England covering all legacy risks
associated with the takeover of the practices
BRP Sept 14 Page 8 of 8
Action plan being implemented
Sept 14

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