Enc K REPORT TO THE TRUST BOARD OF DIRECTORS HELD IN ... · Enc K REPORT TO THE TRUST BOARD OF...
Transcript of 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
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 2016
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
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 2016
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
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 2016
BAF Ref Number
Principle Risk
By
wh
en
LeadAction to meet gaps
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:// ………………
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
Agreement and monitoring of
Quality priorities and targets
(Quality Report / CQUINS)
T
Board Assurance Framework 5
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 2016
BAF Ref Number
Principle Risk
By
wh
en
LeadAction to meet gaps
Gaps in control or
assurance
Link to
Strategic
Objective
Risk Controls AssuranceInternal
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:/ ….
Failure to effectively
deliver healthcare
impacts on the safety
and quality of patient
experience, regulatory
compliance and loss
of confidence of the
wider community
cont:/……..
Failure to effectively
deliver healthcare
impacts on the safety
and quality of patient
experience, regulatory
compliance and loss
of confidence of the
wider community
Subject to external regulation by
the Care Quality Commission
Trust Board &
Quality
Committee
Board Assurance Framework 6
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 2016
BAF Ref Number
Principle Risk
By
wh
en
LeadAction to meet gaps
Gaps in control or
assurance
Link to
Strategic
Objective
Risk Controls AssuranceInternal
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
Workforce metrics snapshot
(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
Board Assurance Framework 7
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 2016
BAF Ref Number
Principle Risk
By
wh
en
LeadAction to meet gaps
Gaps in control or
assurance
Link to
Strategic
Objective
Risk Controls AssuranceInternal
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
Integrated Governance
reports to Trust Board and
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
Integrated Governance
reports to Trust Board and
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:/ ….
Failure to effectively
deliver healthcare
impacts on the safety
and quality of patient
experience, regulatory
compliance and loss
of confidence of the
wider community
TB
C
Quality Assurance
Manager to maintain
database of external
reviews
DN
Q
No central database of
external reviews
Board Assurance Framework 8
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 2016
BAF Ref Number
Principle Risk
By
wh
en
LeadAction to meet gaps
Gaps in control or
assurance
Link to
Strategic
Objective
Risk Controls AssuranceInternal
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
Integrated Governance
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
Integrated Governance
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
Workforce metrics snapshot
(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:/ ….
Failure to effectively
deliver healthcare
impacts on the safety
and quality of patient
experience, regulatory
compliance and loss
of confidence of the
wider community
Arrangements in place for staff
to raise concerns in confidence
Nomination to be
made by Board
Board Assurance Framework 9
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 2016
BAF Ref Number
Principle Risk
By
wh
en
LeadAction to meet gaps
Gaps in control or
assurance
Link to
Strategic
Objective
Risk Controls AssuranceInternal
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
Board Assurance Framework 10
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 2016
BAF Ref NumberGaps in control or
assurance
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 (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
Control - do the assurances
identify that any of the
controls are not working or
not fully implemented? Are
further controls required?
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 managed and objective
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
Board Assurance Framework 11
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 2016
BAF Ref NumberGaps in control or
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
stability due to failure
to deliver the financial
plan resulting in
requirements for
additional CIPs or
reduction in level and
standard of services
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
Board Assurance Framework 12
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 2016
BAF Ref NumberGaps in control or
assurance
Principle Risk
Cross RefAction to meet
gapsB
y w
hen
Le
ad
Link to
Strategic
Objective
Internal
monitoringAssuranceRisk Controls
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
Transformation & Efficiency
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
stability due to failure
to deliver the financial
plan resulting in
requirements for
additional CIPs or
reduction in level and
standard of services
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
Board Assurance Framework 13
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 2016
BAF Ref NumberGaps in control or
assurance
Principle Risk
Cross RefAction to meet
gapsB
y w
hen
Le
ad
Link to
Strategic
Objective
Internal
monitoringAssuranceRisk Controls
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
Internal Audit Report -
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 madeImplementation of
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
stability due to failure
to deliver the financial
plan resulting in
requirements for
additional CIPs or
reduction in level and
standard of services
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
Board Assurance Framework 14
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 2016
BAF Ref NumberGaps in control or
assurance
Principle Risk
Cross RefAction to meet
gapsB
y w
hen
Le
ad
Link to
Strategic
Objective
Internal
monitoringAssuranceRisk Controls
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
stability due to failure
to deliver the financial
plan resulting in
requirements for
additional CIPs or
reduction in level and
standard of services
CF
O
% Reporting purchase
order non
compliance to RAC
quarterly
Internal Audit report on
contract management -
limited assurance
Ind
actio
ne
d
Board Assurance Framework 15
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 2016
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 (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)
Workforce metrics snapshot
(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
Workforce metrics snapshot
(FR&C) / Quarterly
Workforce Information
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?
Control - do the assurances
identify that any of the
controls are not working or
not fully implemented? Are
further controls required?
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
Board Assurance Framework 16
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 2016
BAF Ref Number
Principle Risk
AssuranceGaps in control or
assurance
Internal
monitoring
Link to
Strategic
Objective
Risk ControlsAction to meet
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
Workforce metrics snapshot
(FR&C) / Quarterly
Workforce Information
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
strategic objectives.
results of Workforce Race
Equality Standard report
indicates lower BME staff
engagement
Board Assurance Framework 17
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 2016
BAF Ref Number
Principle Risk
AssuranceGaps in control or
assurance
Internal
monitoring
Link to
Strategic
Objective
Risk ControlsAction to meet
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 ?
HR Strategy in place
fro
m g
reen
-
Ju
ly 2
016 F&R Committee
/ Trust Board
Board approval of HR
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
strategic objectives.
Finance &
Resources
Committee /
Trust Board /
TEG
R794
R828
R900
R905
R913
R922
R925
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.
RISK OWNER: DHR
TProgress being made to embed
workforce planning into
business planning cycle
Board Assurance Framework 18
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 2016
BAF Ref Number
Principle Risk
AssuranceGaps in control or
assurance
Internal
monitoring
Link to
Strategic
Objective
Risk ControlsAction to meet
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
Internal Audit Report -
Temporary Staffing (Limited
Assurance)Ind Apr-16
% Recommendations madeImplementation of
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
* Monthly nurse staffing
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
* Monthly nurse staffing
reportsT May-16
Consultant Job Planning
Internal Audit Report -
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:/ ...........
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.
Board Assurance Framework 19
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 2016
BAF Ref Number
Principle Risk
AssuranceGaps in control or
assurance
Internal
monitoring
Link to
Strategic
Objective
Risk ControlsAction to meet
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)
HR Strategy in place
fro
m g
reen
-
july
2016 F&R Committee
/ Trust Board
Board approval of HR
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
Board Assurance Framework 20
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 2016
BAF Ref Number
Principle Risk
AssuranceGaps in control or
assurance
Internal
monitoring
Link to
Strategic
Objective
Risk ControlsAction to meet
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
Workforce metrics snapshot
(FR&C) / Quarterly
Workforce Information
Report (TB)T Dec-15
Transformation & Efficiency
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
Board Assurance Framework 21
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 2016
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 (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 managed and objective
being delivered
Receiv
ed
Tru
st (T
) or In
dependent (In
d)
Control - do the assurances
identify that any of the
controls are not working or
not fully implemented? Are
further controls required?
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
Board Assurance Framework 22
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 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
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
Board Assurance Framework 23
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 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
Risk ControlsInternal
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
Board Assurance Framework 24
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 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
Risk ControlsInternal
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
effectively with partner
organisations and the
local community
threatens the ability of
the Trust to deliver its
strategic ambition.
Board Assurance Framework 25
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 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
Risk ControlsInternal
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
effectively with partner
organisations and the
local community
threatens the abilty of
the Trust to deliver its
strategic ambition.
Trust Board /
CoG
fro
m g
reen
- j
uly
2016
Board Assurance Framework 26
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 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
Risk ControlsInternal
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
Board Assurance Framework 27
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated July 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
Risk ControlsInternal
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
Board Assurance Framework 28
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated - July 2016
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 (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
Control - do the assurances
identify that any of the
controls are not working or
not fully implemented? Are
further controls required?
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
Board Assurance Framework 1
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated - July 2016
BAF Ref Number
Principle Risk
Cross RefAction to meet
gapsB
y w
hen
Le
ad
Gaps in control or
assuranceRisk Controls Assurance
Link to
Strategic
Objective
Internal
monitoring
BAF (9)Information Governance
Arrangements in Place
IG Committee /
FRC
IG Toolkit Submission T Mar-16
Internal Audit Report -
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
Board Assurance Framework 2
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated - July 2016
BAF Ref Number
Principle Risk
Cross RefAction to meet
gapsB
y w
hen
Le
ad
Gaps in control or
assuranceRisk Controls Assurance
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
development updates to
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
Board Assurance Framework 3
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated - July 2016
BAF Ref Number
Principle Risk
Cross RefAction to meet
gapsB
y w
hen
Le
ad
Gaps in control or
assuranceRisk Controls Assurance
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
development updates to
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
Board Assurance Framework 4
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated - July 2016
BAF Ref Number
Principle Risk
Cross RefAction to meet
gapsB
y w
hen
Le
ad
Gaps in control or
assuranceRisk Controls Assurance
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
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
Board Assurance Framework 5
Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated - July 2016
BAF Ref Number
Principle Risk
Cross RefAction to meet
gapsB
y w
hen
Le
ad
Gaps in control or
assuranceRisk Controls Assurance
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
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
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
Board Assurance Framework 6
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