Meeting Date: 28th January 2016 SUMMARY REPORT Agenda … · The BAF and Corporate Risk Registers...

1 Accountable Director: Julie Thornby, Director of Corporate AffairsBoard Meeting: January 28th 2016

SUMMARY REPORT

Meeting Date: 28th January2016

Agenda Item:Enclosure Number:

eting: Board MeetingTitle: Governance ReportAuthor: Peter Foord, Corporate Risk Manager

Accountable Director:Julie Thornby, Director of Corporate AffairsPeter Phillips, Non-Executive Director, Chairman of the AuditCommittee

Other meetingspresented to orpreviously agreed at:

Committee Date ReviewedKeyPoints/Recommendationfrom that Committee

Audit Committee 5th January 2016

Purpose of the report1. Governance report

For the Board to consider if the Board Assurance Framework(BAF) and Corporate Risk Register capture our main risks, andgive Board members enough assurance about how we aremitigating risks affecting our organisational objectives.

2. Audit Committee Report

To brief the Board about key points from the Audit Committeemeeting held on 5th January 2016. To ask the Board to consider ifthere are any additional assurances needed.

Consider forAction

Approval Assurance

Information

Strategic goals this report relates to:To deliver high

quality careTo support people tolive independently at

home

To deliver integratedcare

To developsustainablecommunity

services

Summary of key points in report1. Governance report

The Audit Committee has reviewed the BAF entries, and has considered the BAF and riskmanagement as a whole against the risk management aspects of the CQC Well Led domain. It hasconcluded that the entries are the right strategic risks against the organisational objectives but

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10.5

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requested that lead directors consider some specific issues as they reviewed entries for:

-Financial Targets-Transformation: Local and National Contexts-Transformation: Systems-Fire Arrangements.

The BAF and Corporate Risk Registers have been reviewed and updated by Lead Directors, takingaccount feedback from Committees where relevant.

Attached is the current Board work plan for reference and ensuring coverage.

The Trust’s annual hospitality register is attached in the interests of being open.

2. Audit Committee Report – key points from discussion:

The Business Strategy and Service Line Reporting system will be further developed in the comingyear.

National guidance has been received for the appointment by Trusts of their external auditors infuture. The Trust will need to appoint an auditor panel to oversee the procurement process andmake a recommendation to the Board on which company should be appointed. The Committee isrecommending to the Board that it should take on the role of Auditor Panel.

The Committee received information from the Trust’s Chief Pharmacist in relation to additionalassurances it had requested about the number of sponsorships for diabetes nursing training ,following the presentation of the annual Trust hospitality report at the October meeting.

The Committee received an update on counter fraud and security management. Self-assessmentagainst NHS Protect standards has shown most areas having a green rating, with some orangerated areas requiring additional work. The Committee approved the renewal of the Anti-BriberyPolicy with minor amendments.

The Audit Committee’s Terms of Reference were approved with minor amendments but subject tofurther change if the Board agrees that the Committee will act as the Auditor Panel (as above).

External Auditors outlined plans for the end of year audit. More detail would be brought to the nextmeeting. The Audit Committee meeting to approve the financial statements has been set for the31st May 2016.

Internal Auditors presented reports for Procurement savings, IT Key Financial Systems, GeneralLedger, and Key Financial Systems. These have been given a green rating, substantial assurance.Assurance Framework and Budgetary Reporting have been given an amber/green rating,reasonable assurance.

Key RecommendationsSection 1, Governance Report

Consider the latest changes to the Board Assurance Framework. Are current significant risks tostrategic objectives accurately captured in the Board Assurance Framework and does it givesufficient assurance on risk mitigation? Approve the framework.

Approve the transfer of the Data Quality risk from the BAF to the Corporate Register

Consider if the Corporate Risk Register includes current Trust wide risks and whether it givessufficient assurance on risk mitigation.

Receive the Board Workplan.


Section 2, Audit Committee Report

Consider if any further assurances are needed.

Agree whether the Audit Committee should take on the role of Auditor Panel for the Trust

Note the Hospitality Report..

Is this report relevant to compliance with any keystandards? YES OR NO

State specific standard orBAF risk

CQC Yes

Aspects of Governance areincluded within the standardsfor Safeguarding and Safety,Suitability of Staffing andQuality and Management.

IG Governance Toolkit NoBoard AssuranceFramework Yes Relates to all entries

Impacts and Implications? YES orNO If yes, what impact or implication

Patient safety & experience Y Good governance processes will have a positiveimpact on the safety and quality of patient care.

Financial (revenue & capital)Y

The Board Assurance Framework details majorfinancial risk which could impact on the Trustobjectives.

OD/Workforce N Inter-relationship between OD and workforceissues and quality

Legal N Various potential legal risks if issues are notmanaged effectively


1.1 Board Assurance Framework

The Audit Committee considered the BAF at its meeting on 5th January 2016. As wellas the entries themselves, the Committee considered the risk management aspectsof the CQC domain for Well Led, against the Monitor/TDA descriptors of goodpractice. The conclusion was that the risks currently featured are the right risksagainst the organisational objectives, and that the following points needed to beconsidered. Those points have been taken into account by the lead directors for therisks, and action has been taken as shown in the two tables that follow.

Risk Committee Recommendation Action takenMeeting Financial Targets Rating should be considered in

light of current position.Financial targets for 15/16 arebeing met through a variety ofmeasures. Risk rating has notbeen changed

Transformation, local andnational contexts

The entry should be reviewedto consider potential changesfrom the longer timeframe forthe Future Fit programme, andany effect on the rating of therisk.

In view of the development of theLHE sustainability andtransformation plan, the rating hasnot been changed

Transformation, systems The risk rating should bereconsidered, taking intoaccount that the EPR projecthad not been approved by theTDA. However approval hasnow been given.

Approval of EPR, risk ratingreduced from 12 to 8

Clinical Quality and Safety Additional assurances wouldstrengthen the presentation ofthe entry, plus ensuring theactions and gaps in assurancealign well.

The Quality and Safety Committeeand the Board at its developmentsession in January, received latestupdate reports on risks thatsupport this entry.

Fire Safety Arrangements The BAF entry for Fire Safetyhas been re-scored, and as aresult transferred from the BAFto the Corporate Register,following discussions at the lastBoard and Audit Committee.The risk has reduced with thework carried out to meet thesafety alert for fire stopping,and improvements to thegeneral fire safetyarrangements.

Current risk rating has beenreduced from 15 to 12.Improvement work is due to becompleted by the end of January.

SECTION ONE: GOVERNANCE REPORT INCLUDING BOARD ASSURANCEFRAMEWORK


1.2 Changes to the BAF since the last Board meeting – including a lead nonexecutive director for each risk

Lead Executive Directors have reviewed their risks and updated where appropriate,taking into account the Committee recommendations above. The table below showschanges made since the last Board meeting. No new risks have been added sincethe last meeting, but some have been or are proposed to be, moved to the CorporateRisk register.

As agreed at the Quality and Safety Committee, a lead non executive director is nowshown for each risk on the BAF, ie the chair of the Committee responsible foroverseeing that risk in our risk framework, as already shown on the BAF.

Ref Title Changes

7-2014 Changing Culture Additional control added ie patient and carer panel, andassociated activities.

1-2014 Clinical Quality

Waiting times have been added to the risk description as a keyindicator. The level of risk has been reconsidered; as there are nocurrent significant issues, the consequence and likelihood, andcurrent rating, remain the same. Two new actions added toaddress gaps in assurance ie for CAMHS, and estates, which willbe taken forward by the Dir. of Strategy

9-2014 Data QualityRating reduced to match the target of 6. It is thereforerecommended to the Board that this risk is transferred to theCorporate Register

6-2014 Meeting Financial Targets15/16

Progress on CIP action plan updated to reflect current position oftargets being delivered by programmes, non-recurrent measuresand capital to revenue transfer.

11-2015 Recruitment/Agency costs

Noted in controls that position is slightly improved. Action aboutprocesses has been closed, as a SOP is in place and exceptionreports where the framework not met.

3-2014 Transformation - Systems

This entry has been updated to reflect approval of the EPR bid.A control has been added for exit strategy on transfer of ITsupport to the CSU.Risk rating has been changed from 12 to 8 due to EPR approval.

2-2014 Transformation -Local andNational Contexts

Additional action added for development of LHE Sustainabilityand Transformation plan

5-2014 Trust Sustainability

An additional control has been added to reflect involvement indevelopment of LHE sustainability and transformation strategyAdditional action added for development of 5 year FinancialStrategy

Risk 9-2014 Data Quality – Proposal to move to Corporate Risk Register

Substantial work has been carried out on control systems, with a level of controlappropriate for the systems in place. There have been no significant issues identified,particularly in relation to data submitted externally. The risk rating has therefore beenreduced from 9 to 6, and it is recommended to the Board that the risk is transferred tothe Corporate Register.


The BAF is attached as Appendix 1.

1.3 Corporate Risk Register

The Audit Committee considered the Corporate Register and it was agreed to givehigher profile to risks which are not currently at target by showing them at the front ofthe report. Lead Directors have reviewed their entries on the Corporate Risk Register,and in doing so have taken into account comments from the Quality and SafetyCommittee.The register is attached for reference as Appendix 2.

1.4 Board Workplan

The current Board workplan is attached as Appendix 3 for the Board’s reference.

1.5 Trust Annual Hospitality Report

At its last meeting, the Board reviewed its position in relation to NHS Codes of Conductfor Boards, as a matter of good practice. The Board agreed that an extra step it couldtake in order to be as open as possible was to bring the annual Trust hospitality report,(which had been considered by the Audit Committee) to the Board in public and this isattached as Appendix 4.

2.0 The Committee met on 6th October 2015.

Main assurances to the Board

This report details the main assurances discussed and received at the meetingagainst key risk areas.

2.1 Business Strategy/Service Line Reporting

The committee heard that the Director of Strategy would be taking this work forwardwith the newly appointed deputy. For Service Line Reporting commissioners willmonitor the progress made. The EPR system is an essential component of thisreporting.

2.2 Appointment of External Auditors

National guidance has been issued on how to meet the new legislative requirement forTrusts to appoint their own external auditors, to be in place for 2017/18. Trusts arerequired to have in place an Auditor Panel to oversee the process for selecting anexternal auditor, and recommending the appointment to the Trust Board. Theguidance proposes that Audit Committees may be the natural choice for Trusts, astheir membership has the appropriate independence.(Subject to confirming that themembers have no conflict of interest with potential external audit companies egthrough being recent employees.) The Board will need to appoint an auditor paneland run a procurement process before the end of the calendar year, in order to be in a

SECTION TWO: Audit Committee Report


position to have appointed for 2017/18. The Audit Committee recommends to theBoard that it should take on this role, and that its terms of reference should berevised to reflect this, and brought to the next Board for approval. In themeantime, initial work with procurement on the process could begin, noting that a jointprocurement process may be considered with other Trusts.

2.3 Service Level Agreements (SLA)

Following an Internal Audit report which gave limited assurance, and discussions atthe last meeting the Committee received the latest position, with management effortneeding to be concentrated on the higher value agreements, and progress to bemade in the next few weeks.

2.4 Trust Annual Hospitality Report

Assurances were provided from the Chief Pharmacist that there was no evidence ofthe diabetes nursing team’s prescribing patterns (via electronic prescribing records)being influenced by pharmaceutical company sponsorships of training courses for thisstaff group. The Committee had asked for this assurance having seen the Trustannual hospitality report.

2.5 Compliance with CQC

The Committee received a report on compliance with CQC standards.

2.6 Counter Fraud and Security Management

The Committee received an update report from the Local Counter Fraud and SecurityManagement Specialist. The report highlighted that the Trust has a green ratingagainst most of the NHS Protect standards for Counter Fraud and SecurityManagement, and is prioritising areas scored amber for improvement dependant ontheir weighting. The Committee approved the review of the Anti-bribery Policy andProcedure.

2.7 Terms of Reference

The committee approved minor changes to its terms of reference and noted that theywill require updating if the Board approves the recommendation for the Committee tobe the Trust’s Auditor Panel.

2.8 Clinical Audit Update

The Committee received a short report on the Clinical Audit Programme, and asked formore assurance in future on the findings from the clinical audits, and assurances thatlocal clinical audits have been actively used to provide assurances against our knownclinical risks where relevant, including the risk entry on the BAF.

2.9 Risk Registers

The Committee considered the Corporate Risk Register which it receives each time,and the Finance Directorate Risk Register as part of its rolling program for receivingrisk registers.

2.10 External Audit

Auditors set out in brief the programme for the end of year. The Value for Money Auditis changing, and information will be brought to the next meeting. The extraordinary


meeting of the Audit Committee to consider the financial statements is planned for 31st

May 2016.

2.11 Internal Audit

Auditors gave their progress report. Audits for Procurement savings, IT Key FinancialSystems, General Ledger, and Key Financial Systems have been given a green rating,substantial assurance. Assurance Framework and Budgetary Reporting have beengiven an amber/green rating, reasonable assurance.

3 Recommendations to the Board

Section 1. Audit Committee Report

Consider the latest changes to the Board Assurance Framework. Are current significant risks tostrategic objectives accurately captured in the Board Assurance Framework and does it givesufficient assurance on risk mitigation? Approve the framework.

Approve the transfer of the Data Quality risk from the BAF to the Corporate Register

Consider if the Corporate Risk Register includes current Trust wide risks and whether it givessufficient assurance on risk mitigation.

Receive the Board Workplan and Trust Annual Hospitality Register

Section 2. Audit Committee Report

Consider if any further assurances are needed.

Agree the recommendation from the Audit Committee that it should take the role of Trust AuditorPanel, overseeing the procurement of external auditors for 2017/18 as required in legislation

Rating (current)

The direction of the arrow shows the lead director’s opinion of the risk direction:

Risk is level Risk is improving Risk is worsening

The colour within the arrow shows the current level of risk: High, Moderate, Low, Very Low

Objectives with no risks currently identified

Principal objectives Ref ID Title Rating(current) Lead Director Monitoring

Group Page

: Assurance FrameworkSAFE - people are protectedfrom abuse and avoidableharm.

11-2015 2319 Recruitment/Agency

costs

20Gregory, MrSteve

Quality and SafetyCommittee

14

MAKING BEST USE OFTECHNOLOGY - we willdeploy technology to improvepatient care and increaseefficiency ensuring the rightinformation is available to theright people at the right timeregardless of the care setting.

3-2014 1994 Transformation -

Systems

12

Ros FranckeResource andPerformanceCommittee

5

WELL LED - the leadership,management and governanceof the organisation assure thedelivery of high qualityperson-centred care, supportlearning and innovation, andpromote an open and fairculture

7-2014 1998 Changing Culture

12

Ditheridge, MsJan


10

EFFICIENT - We will reviewservices to deliver asefficiently as possibleenabling reinvestment inpatient care.

5-2014 1996 Trust Sustainability

12


7

EFFICIENT - We will reviewservices to deliver asefficiently as possibleenabling reinvestment inpatient care.

6-2014 1997 Meeting Financial

Targets

12


9

GROW - we will seekopportunities to extend therange and scale of servicesdelivered in the community.

2-2014 1993

Transformation -Local and NationalContexts

8Gregory, MrSteve

Resource andPerformanceCommittee

3

SAFE - people are protectedfrom abuse and avoidableharm.

1-2014 1992 Clinical Quality

6 Gregory, MrSteve


1

MAKING BEST USE OFTECHNOLOGY - we willdeploy technology to improvepatient care and increaseefficiency ensuring the rightinformation is available to theright people at the right timeregardless of the care setting.

9-2014 2000 Data Quality

6


11

CARING – staff involve and treat people with compassion, kindness, dignity and respect.

RESPONSIVE - services are organised so that they meet people’s needs.DESIGNED AROUND THE PATIENT - Our services will be continually reviewed and modified placing thepatient at the centre of the redesign. Working across organisational boundaries to deliver integrated care.

EFFECTIVE - Peoples care, treatment and support achieves good outcomes, promotes a good quality oflife and is based on the best available evidence.

DELIVERED IN SUITABLE ENVIRONMENTS - we will review the use of our estate and develop whereappropriate.

BAF Index January 2015

FoordPJ

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Appendix 1

Ref

ID Title Rat

ing

(cur

rent

)

Ris

k le

vel (

curr

ent)

Manager Source of Assurance Ass

urac

e Rat

ing

New Assurances1-

20141992 Clinical Quality 6 L

OW

Mr SteveGregory

Summary reports for quality standards, Q&SCommittee and Board

No new assurances

Monthly Clinical Quality Reviews byCommissioners

No new assurances

Reviews by regulators, actioned whennecessary

No new assurances

Visits and reports by Healthwatch All hospitals have been visited and appropriate actionsdeveloped. Visits were positive with minor issues being raised.Bishops Castle had no issues.

Quality Account Planning for 15/16

Annual reports - Clinical Audit, Mortality,Medicines, Health and Safety

No new reports

Infection Prevention and Control Group(reports)

No new assurances

Board to team visits No new assurances2-

20141993 Transformation

-Local andNationalContexts

8 MOD

RosFrancke

Transformation report to R&P/Board detailingFuture Fit progress and associated programmesof work

Development of LHE Sustainability and Transformation Plan

Scope of Better Care Fund proposals No new assurances

3-2014

1994 Transformation- Systems

12 MOD

SteveGregory

Project reports to Board via R&P TDA approval of EPR business case

Business cases reported via R&P As above

Formal project structure and reports toR&P/Board

No new assurances

5-2014

1996 TrustSustainability

12 MOD

RosFrancke

Implementation of strategic workstreams No new assurances

Contract negotiations concluded for 16/17 No new assurances

Progression with Integrated Care Service andother Better Care Fund Initiatives

No new assurances

6-2014

1997 MeetingFinancial

12 MO

RosFrancke

External audit of accounts No new assurances

BAF – Assurance Status

Targets D External value for money audit No new assurances

Financial systems audit by internal auditors Green rating for financial systems 15/16 audit

Financial reports to Board No new assurances

Plan in place for 15/16 with target surplus Plan on target with current programmes, non-recurrentschemes and TDA agreen capital to revenue transfers

Initial TDA review of CIP processes No new assurances

Internal audit of CIP process Audit Positive relating to CIP process

7-2014

1998 ChangingCulture

12 MOD

Ms JanDitheridge

Trust dashboard No new assurances

Staff Survey No new assurancesResponses to national initiatives and guidance No new assurancesReports by Internal Audit No new assurances

HR statistical reports No new assurances

9-2014

2000 Data Quality 9 MOD

RosFrancke

Annual Value for Money report by ExternalAudit

External Audit gave unqualified opinion for VFM

Positive data quality report from Internal AuditAug 14

No further reports

Financial and performance reporting No new assurances

11-2015

2319 Recruitment/Agency costs

20 HIGH

Mr SteveGregory

Staffing and workforce reports Position improved with recruitment to Stoke Heath, nearly fullstaff compliment. Other areas continue to improve theirsubstantive staff.

12-2015

2317 Fire SafetyArrangements

15 MOD

Mrs SarahLloyd

Reports to R&P Committee Reports indicate positive movement on fire improvement workcarried out

Fire Brigade inspection/advice planned for6/10/15

No new assurances

Trust Fire Adviser providing independent advice No new assurances

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.Risk Controls Assurance Gaps in Control Gaps in AssuranceRisk to the delivery of theobjective(s) How will these risks be managed or controlled

What and from what source is theevidence that the risk controls areeffectiveNON = Internal AssuranceINDEP = Independent Assurance

What extra controls areneeded to manage the risk

What extra evidence isrequired that the risk controlsare effective

Clinical Quality 6

Datix ID

Initial ratingC x L

Lead Mr Steve Gregory 6

4 X 3 3 xx 2 3 21992

12Risk Indicator

Current ratingC x L

Target ratingC x LNon Exec. Lead Rolf Levesley

Ref No 1-2014

Changes since last update Waiting times have been added to description as a key indicator. Consideration to the level of risk has been made, as there are no current significantissues the consequence and likelihood, and current rating, remain the same. Two new actions added for CAMHS, and estate, which will be taken forwardby Dir. of Strategy

Monitoring of quality standards, e.g. CQUINS, pressure ulcers, falls,VTE assessment and treatment, UTIs, waiting times.Quality impact assessment for service changes.Clinical Audit program.Divisional challenge meetings related to quality. e.g. CQC, Pressureulcers.Quality improvement initiatives. e.g Harm free care.Trustwide self monitoring of standards.Quality performance monitoring, MPR, Dashboard, Incidents.complaints and claims monitoring, Safety ThermometerInvestigation and subsequent actions from SIs, complaints, claims andunexpected death reviews/Mortality Group reviewStaff training ( mandatory and essential skills)CQC evidence reviewsInfection prevention and control workplan.Role specific essential training in placeSPC reporting in place to identify outlying eventsSafeguarding arrangements in place (training, reporting, supervisionand internal group monitoring)

NON Summary reports for qualitystandards, Q&S Committeeand Board

INDEP Monthly Clinical QualityReviews by Commissioners

INDEP Reviews by regulators,actioned when necessary

INDEP Visits and reports byHealthwatch

NON Quality Account

NON Annual reports - ClinicalAudit, Mortality, Medicines,Health and Safety

NON Infection Prevention andControl Group (reports)

NON Board to team visits

INDEP LA Safeguarding Boards (4)scrutiny of Trustarrangements

Control of EstatesManagementCAMHS

RISKQuality of care fails to meet the needs andexpectations of public.Quality of care does not meet targets set bycommissioners.Financial constraints compromise quality andsafety.CQC essential standards not met.

CONSEQUENCEHarm caused to patients.Increased time and cost of patient care.Loss of public confidence.Enforcement action by regulators.Services lost to other providers.Litigation time and costs.Increased staff turnover, difficulties withrecruitment.Increased waiting times

Printed 19 Jan 2016Page 1

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ByDueProgressAction Status

Actions required to address any gaps in control or assurance

31-Jan-2016To learn from Trusts who have undergone new styleCQC inspection and prepare for when the Trust hasto be inspected

Preparations have been completedCompleted Peter Foord

31-Mar-2016CAMHS:Work with commissioners to agree servicemodel that meets patient need. This will ensure thatwe have the right staff with the right skills.

In progress

31-Jul-2016As part of CQC arrangements evaluation recruit 2heads of Nursing and Quality. Review arrangementsin 6 months

Staff appointed for 6 months, review scheduledfor July

In progress

31-Jul-2016Review of Facilities and Estates service to take place.Review of the Estate we operate from. E.g. leasedproperties

In progress

CQC LinksE1: Are people's needs assessed and care and treatment deliveredin line with legislation, standards and evidence-basedE2: How are people's care and treatment outcomes monitored andhow do they compare with other servicesE3: Do staff have the skills, knowledge and experience to delivereffective care and treatment?E4: How well do staff, teams and services work together to delivereffective care and treatment?E5: Do staff have all the information they need to deliver effectivecare and treatment to people who use services?E6: Is people's consent to care and treatment always sought in linewith legislation and guidance?R3: Can people access care and treatment in a timely way?R4: How are people's concerns and complaints listened andresponded to and used to improve the quality of care?S1: What is the track record on safetyS2: Are lessons learned and improvements made when things gowrongS3: Are there relliable systems, processes and practices in place tokeep people safe and safeguarded from abuseS4: How are risks to people who use services assessed and theirsafety monitored and maintainedS5: How well are potential risks to the service anticipated andplanned for in advance

Residual Risks Monitoring Group Quality and Safety Committee


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Risk Controls Assurance Gaps in Control Gaps in AssuranceRisk to the delivery of theobjective(s) How will these risks be managed or controlled




Transformation -Local and National Contexts 8

Datix ID

Initial ratingC x L

Lead Ms Mel Duffy 8

4 X 4 4 xx 2 4 21993

16Risk Indicator

Current ratingC x L

Target ratingC x LNon Exec. Lead Steve Jones

Ref No 2-2014

Changes since last update Additional action added for development of LHE Sustainability and Transformation plan

1. Future Fit Programme is the main strategic planning vehicle acrossthe health economy, active engagement at all levels includingdevelopment of clinical models is a key control.2. CEO and Director engagement with partner organisations.3. CEO Group.4. Involvement in national networks.5. Increased clinical engagement in strategy and transformationprogramme.6. Stronger system of business planning.7. Development of additional projects connected to future fit, i.e.community services and urgent care.8. Trust has taken a leadership role in the planning of rural urgent carecentres project.9. Community Fit projects commenced with initial information gatheringand analysis to be completed by December.10.Trust has initiated development of a strategy for the future use ofcommunity hospitals, including MIUs.

NON Tansformation report toR&P/Board detialling FutureFit progress and assocatedprogrammes of work

NON Scope of Better Care Fundproposals

Full development ofcommunity offer andrelated engagement withstakeholders.Scope of commissionerled urgent care centredevelopment has yet tobe defined

RISK1.The increasing pressure to address urgent careservices in the local health economy may hinderthe successful development and implementation ofstrategic solution that delivers a shift towardsgreater community provision. This may skew thepriorities within the Future Fit programme.2. The focus on hospital care within Future Fit mayresult in resources being prioritised in acuteservices at the expense of a longer term vision thatfocuses on supporting people to live at home.3. Future Fit acute options consultation postponedto Summer 2016 due to affordability assessmentCONSEQUENCES1.Opportunities to integrate services reduced.2.Sustainability of some services reduced.3.Potential to support more patients at homereduced therefore greater pressure on acute care.



Re-enforce importance of community offer within andalongside future fit programme.

Community fir data analysis on track forcompletion April 2016.

In progress Ms Jan Ditheridge

30-Jun-2016In conjunction with system parties compile a healtheconomy sustainability and transformation plan tounderpin future development

CQC LinksR1: Are services planned and delivered to meet the needs of people?

R2: Do services take account of the needs of different people,including those in vulnerable circumstances?S1: What is the track record on safetyW1: Is there a clear vision and a credible strategy to deliver goodqualityW3:How does the leadership and culture reflect the vision andvalues, encourage openness and transparency and promote goodquality careW4: How are services continuously improved and sustainabilityensured

Residual Risks Monitoring Group Resource and Performance Committee


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Transformation - Systems 6

Datix ID

Initial ratingC x L

Lead Ms Ros Francke 8

3 X 4 2 xx 4 3 21994

12Risk Indicator

Current ratingC x L


Ref No 3-2014

Changes since last update Entry has been updated to reflect approval of EPR bid.Control added for exit strategy on transfer of IT support to CSURisk rating has been changed from 12 to 8 due to EPR approval.

Development of system specifications.Governance arrangements in place for managing the introduction ofEPR systemsIntroduction of interim work around'sDevelopment of electronic workplace scheduler toolUse of manual recording systemsCommissioner funding received for HV remote working, pilot underwayIT department structured to minimise staffing risk and project plan inplace in place to manage the exit strategy and device transfer to CSU

NON Project reports to Board viaR&P

NON Business cases reported viaR&P

NON Formal project structure andreports to R&P/Board

INDEP EPR business case approvedverbally via the TDA

As servicetransformation becomesmore defined, systemswill need to bedeveloped to meetservice needs, whichmay identify risk wherefurther controls need tobe implemented.

RISKSTrust is not able to develop information systems tomeet future service needs.Trust currently uses a mixture of manual andelectronic systems leading to productivity, datacapture and data quality issues.Multiple systems not allowing cross disciplinerecord keeping.Lack of opportunity for mobile working.CSU has served notice on Trust providing ITsupport to GPs, if service is lost viability of Trustservice is reduced.

CONSEQUENCESServices do not develop fast enough.Potential financial risks associated with tariffpayments.Costs of system development.



31-Mar-2016Progress EPR solution EPR business has been signed off by TDA.In progress

31-Mar-2016Bid for service once the tender is advertised Service is not being tenderedAction will not becompleted

CQC LinksE4: How well do staff, teams and services work together to delivereffective care and treatment?E5: Do staff have all the information they need to deliver effectivecare and treatment to people who use services?S4: How are risks to people who use services assessed and theirsafety monitored and maintainedW4: How are services continuously improved and sustainabilityensured

Residual Risks Ability to respond to new datarequirement e.g fromcommissioners and nationalbodies. Technological limitationsbetween data systems.

Monitoring Group Resource and Performance Committee


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Trust Sustainability 8

Datix ID

Initial ratingC x L


4 X 5 4 xx 3 4 21996

20Risk Indicator

Current ratingC x L


Ref No 5-2014

Changes since last update An additional control has been added to reflect involvement in development of LHE sustainability and transformation strategyAdditional action added for development of 5 year Financial Strategy

Delivery of commercial approach.Contract discussions with commissioners, including changes indemand.Efficiency - focus on reduction of overhead costs.Process to identify tender opportunities.Engagement with commissioners on development of better care fund.Local health economy DoF group.Development of closer working relationships with commissioners at alllevels.Development of investment policy to focus business developmentresource on appropriate areas for growth.Business Development Group stronger role and tighter relationship withR&P.New Business Investment Policy introduced to clarify decision makingprocess and level of delegation.Business Planning process in 2015/16 reviewed. Growth potential withineach service area and priorities have been defined.Engagement in the planning requirements 16/17 of a 5 year LHEsustainability and transformation plan (also added as an action toTransformation risk)

INDEP Implementation of strategicworkstreams

NON Contract negotiationsconcluded for 15/16

INDEP Progression with IntegratedCare Service and other BetterCare Fund Initiatives

Lack of a 5 yearFinancial Strategy

RISKSTrust does not grow sufficiently to sustain itsservices.Block contracts, rather than tariff, do not meetincreases in demands.Service tenders are awarded to other providers.Trust fails to diversify to reduce risks associatedwith a constant service base.CONSEQUENCETrust cannot sustain its overhead costs and remaincompetitive.


Obj

ectiv







Develop a timetable and implementation plan for asystem to produce service line reporting

In progressIn progress Ms Ros Francke

31-Mar-2016Complete roll out of ICS and secure recurrent funding In progress Mr Steve Gregory

31-Mar-2016Increase understanding of capacity and demand toinform negotiation of block contracts

In progress Ms Ros Francke

31-Mar-2016Implementation and review of new MSK service Service commenced 1st September, a reviewto be completed following commencement.

In progress Mr Steve Gregory

30-Jun-2016Development of the 5 year Financial Strategy Initial parameters set using 16/17 planningguidance and future development will takeplace over the next few months.

In progress

CQC LinksC1: Are people treated with kindness, dignity, respect andcompassion while they receive care and treatmentW1: Is there a clear vision and a credible strategy to deliver goodqualityW2: Does the governance framework ensure that responsibilities areclear, and that quality, performance and risks are understood andmanaged?W4: How are services continuously improved and sustainabilityensured

Residual Risks Ongoing LHE financialchallenges. Potential fortendering of services bycommissioners



Obj

ectiv

eE

FFIC

IEN

T-W

e w

ill re

view

serv

ices

to d

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s ef

ficie

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as p

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ble

enab

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rein

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patie

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are.





Meeting Financial Targets 15/16 9

Datix ID

Initial ratingC x L


5 X 5 3 xx 4 3 31997

25Risk Indicator

Current ratingC x L


Ref No 6-2014

Changes since last update Progress on CIP action plan updated to reflect current position of targets being delivered by programmes, non-recurrent measures and capital torevenue transfer.

Financial monitoring by managers, reported to R&PLong Term Financial Model (LTFM)CIP program and monitoring.Renewed focus and emphasis on CIP development andimplementation.Forward CIP plan being developed.PMO function in place.CIP delivery group and Transformation and CIP board in place.Financial Forecasting - reported to R&P and BoardCapital and Estates Group established to manage capital expenditure.Cash Management Processes to manage EFL well developed.CIP escalation process in place and meetings held.Non recurrent measures to be identified to offset shortfalls againstrecurrent CIP in short term.Forecast COS rating of 4 maintained.QEIA process in place including NED membership.Fortnightly CIP delivery meetings

INDEP External audit of accounts

INDEP External value for moneyaudit

INDEP Financial systems audit byinternal auditors

NON Finanical reports to Board

NON Plan in place for 15/16 withtarget surplus

INDEP Initial TDA review of CIPprocesses

INDEP Internal audit of CIP process

CIPs not fully developedfor 15/16 in light ofincreased surplusrequirement

RISKTrust fails recurrently to meet targets for CIPs,breakeven, external finance limit, capitalexpenditure or agreed surpluses.There are challenges in both long and short term.Increased surplus agreed with TDA in August thishas increased our CIP requirement with limitedtime to identify additional schemes

CONSEQUENCELong term future and viability compromised.Service quality affected by financial constraints.



31-Mar-2016Fully develop CIP program for 15/16, includingincreased surplus requirement

Delivery of the Trusts targets are beingdelivered via a mixture or original CIPprogrammes, non- recurrent measures and acapital to revenue transfer facilitated by theTDA

In progress Ms Ros Francke

CQC LinksW2: Does the governance framework ensure that responsibilities areclear, and that quality, performance and risks are understood andmanaged?W4: How are services continuously improved and sustainabilityensured

Residual Risks Local health economy financialchallenges



Obj

ectiv

eW

ELL

LE

D-t

he le

ades

hip,

man

agem

ent a

nd g

over

nanc

e of

the

orga

nisa

tion

assu

re th

ede

liver

y of

hig

h qu

ality





Changing Culture 8

Datix ID

Initial ratingC x L

Lead Ms Jan Ditheridge 12

4 X 4 4 xx 3 4 21998

16Risk Indicator

Current ratingC x L

Target ratingC x LNon Exec. Lead Mike Ridley

Ref No 7-2014

Changes since last update Additional control added for patient and carer panel, and associated activities.

Leadership:Board messaging and visibility.Leadership programme and structure (e.g, CTLG)Organisational Development Framework activitiesStaff Health and Wellbeing Programme.Speak Out Safely/Freedom to Speak Up.Supporting HR policies - e.g. Whistleblowing.Actions will be integrated into Culture Work plan if new issues arise notcovered in the planStaff awaydays nearing completionPatient and external feedback(complaints, PALs, Sit and SEEHealthwatch reports)

NON HR statistical reports

NON Trust dashboard

INDEP Staff Survey

NON Responses to nationalinitiatives and guidance

RISKSStaff aren't happy at work leading to poor patientscare, reduced capacity (through sickness absence)and reduced opportunity for innovation andchange.Potential risk that staff are reluctant to be openabout incidents or practicesNot seen as an organisation people want to workfor - reducing capability and capacity. Reputationand relationships poor.CONSEQUENCESTrust does not deliver new care models to meetchanging needs of patients/carers andcommissioners. Organisation becomesunsustainable.



Establishment of professional services group acrosshealth and social care

Discussions held with social care, have beeninvited to professional leadership meeting.

Completed Mr Steve Gregory

31-Oct-2014Development of new professional lead structure Structure formulatedCompleted Mr AndrewColeman

CQC LinksC1: Are people treated with kindness, dignity, respect andcompassion while they receive care and treatmentC2: Are people who use services and those close to them involvedas partners in their care?C3: Do people who use services and those close to them receive thesupport they need to cope emotionally with their care, treatment orcondition?E3: Do staff have the skills, knowledge and experience to delivereffective care and treatment?E4: How well do staff, teams and services work together to delivereffective care and treatment?R2: Do services take account of the needs of different people,including those in vulnerable circumstances?R4: How are people's concerns and complaints listened andresponded to and used to improve the quality of care?



Obj

ectiv

eM

AK

ING

BE

ST

US

E O

FTE

CH

NO

LOG

Y-w

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ill d

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to im

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e pa

tient

care

and

incr

ease





Data Quality 6

Datix ID

Initial ratingC x L


3 X 4 3 xx 2 3 22000

12Risk Indicator

Current ratingC x L


Ref No 9-2014

Changes since last update Rating changed to target of 6. Recommendation that this risk is transferred to the Corporate Register

Information collation into data warehouse.Validation of data by informatics and operations managers.Data quality indicators on all metrics on the performance report.In phase software for performance reporting.Data cleansing on waiting times to ensure accuracy for non RTTservices.Reduced target timescale for data capture.Performance Management Framework developed to provide greaterfocus on metrics.

INDEP Reports by Internal Audit

INDEP Annual Value for Moneyreport by External Audit

RISKData relating to Trust performance is inaccurate oris not available in a timely way.Concerns relate to clinical activity data and someHR data.Information collected in several systems leading tocollation problems.

CONSEQUENCEInadequate information to support decision making.Inaccurate costings.Not being able to demonstrate accuratelycompliance with performance targets.Potential risks to income.



31-Jul-2014Review timescale for data entry across operations Completed Mrs Tessa Norris

31-Jul-2014Implement recommendations from the internal auditof data quality.

Completed Trish Donovan

31-Dec-2014Implement and embed In Phase software forperformance reporting across all areas

UnderwayCompleted Lee Osbourne

31-Dec-2014Deliver data quality improvement plan Elements of data quality audit have beenreviewed and those relating to systemoperating procedures will be addressedthrough the EPR project.

Completed Lee Osbourne

31-Dec-2015Implement Performance Management Framework PMF now rolled out across clinical servicesand corporate functions

Completed Ms Ros Francke

CQC LinksE5: Do staff have all the information they need to deliver effectivecare and treatment to people who use services?R3: Can people access care and treatment in a timely way?W2: Does the governance framework ensure that responsibilities areclear, and that quality, performance and risks are understood andmanaged?


Obj

ectiv





Residual Risks Monitoring Group Resource and Performance Committee


Obj

ectiv

eS

AFE

-peo

ple

are

prot

ecte

dfro

m a

buse

and

avo

idab

le h

arm

.Risk Controls Assurance Gaps in Control Gaps in AssuranceRisk to the delivery of theobjective(s) How will these risks be managed or controlled




Recruitment/Agency costs 9

Datix ID

Initial ratingC x L

Lead Mr Steve Gregory 20

5 X 4 5 xx 4 3 32319

20Risk Indicator

Current ratingC x L

Target ratingC x LNon Exec. Lead Rolf Levesley

Ref No 11-2015

Changes since last update Noted in controls that position is slightly improved. Action closed for process, SOP in place and exception reports where framework not met.

Backfilling with agency staff to ensure safe staffing levelsRecruitment campaignsControl techniques to reduce patient safety risk e.g. mix of permanentand agency, long term staff where appropriate and workplace induction.Planned closure of escalation beds with LHE agreementWeekly meetings to monitor agency use for Adult services, monthly forChild and FamilyBed state taken into account for agency useValues based recruitmentlonger term agency assignments will be challenged and if authorisedwill be monitored through Oracle to ensure the framework is usedWeekly review of agency usage for community hospitalsPosition is improved from previous months

Financial and performancereportingStaffing and workforce reports

RISKDifficulty in recruiting staff to Community Hospitals,Prisons, CAMHS and ICS. Increased use of bothshort and long term agency staff leading tofinancial risks.With increasing demand for agency staff prices arebeing driven up.Where ID medical cannot meet demand Thornburyagency staff are used at additional cost.TDA have issued new guidance on the use ofagency staffCONSEQUENCEAdditional agency spend is estimated at £500k permonth, with a potential annual cost >£6millionPotential for increased patient safety risks


Obj

ectiv







7-Jul-2015Confirmation of framework agencies andcommunication to all line managers to instruct them touse only these.

Has been completed but will need to reviewdue to new TDA guidance

Completed Mr Andy Matthews

24-Jul-2015De-escalation of beds to remove 9 (106 reduced to97) to reduce agency demand

CompletedCompleted Mr Andy Matthews

31-Jul-2015Amalgamate wards at Ludlow Hospital CompletedCompleted Mr Andy Matthews

30-Nov-2015Review DOH directive on agency use, along withNHSE/ Monitor framework. This will cap day andhourly rate.

SOP in place, exception reports where cannotbe met

Completed Sally-AnneOsborne

31-Dec-2015Scope the value for money arrangement with currentprovider (ID Medical) or an alternate model egin-house processes

Agreement signed with ID, meeting currentrequirements

Completed Sally-AnneOsborne

31-Mar-2016Develop a workforce plan to mitigate the need foragency workers eg plan recruitment in advance basedon workforce trends

In progress, Workforce planning workshopplanned

In progress Sally-AnneOsborne

CQC LinksE3: Do staff have the skills, knowledge and experience to delivereffective care and treatment?S5: How well are potential risks to the service anticipated andplanned for in advance



Obj

ectiv






Risk Register Report - Risks above Target Level Register Level Corporate Risk Register

Register Area All Directorates

325Risk ID no Risk Title Business Interuption

AdministrationArea/Division

AdministrationService

Where the risk applies to Nature of the riskIndividual business continuity service plansCorporate business continuity planHeatwave plansDoH, TDA and NHSE guidanceDedicated support for emergency planning and business continuityRegular exercise to test plans and review.Review of plans following incidentsAnnual review of Business Continuity PlansMulti agency register of localised risksHealth Economy Planning for peaks in demand

Controls Currently in Place to mitigate the riskRobust business continuity plans are necessary to ensure that shouldeither foreseen or unforeseen circumstance occur which compromiseservices then rehearsed and documented plans can be quickly initiated tomanage the safety of these services. Some realignment is necessary ofexisting plans to fit in to the new organisational structures.Example of circumstances are:Adverse weather conditionsFuel ShortagesIllness (e.g. flu pandemic)Industrial ActionHeatwaveThere are particular issues with snow and ice, and getting to remotecommunity locations

Division All Directorates

Manager Leading on the Risk Mr Steve Gregory

MonitoringGroup


Level of Risk with no controlCurrent Level of the RiskLevel of Risk to be achieved

Cons Like Rating

912

634

33

2 3

Description Progress Who is responsible Due date Date Done StatusEstablish regular BCMmanager forum.

Progress ongoing 31-Dec-2015Pete Old In progress

Specific plans need to bedeveloped for totalevacuation procedure andlockdown These relate inthe main to hosptials

Work is progressing onplans, and what additionalactions may be necessary toachieve an appropriate levelof protection

31-Mar-2015Pete Old In progress

How the Risk is Rated Additional controls and actions required to mitigate the risk

966Risk ID no Risk Title Community links and Reputation



Where the risk applies to Nature of the risk- Patient and Carer Panel in place- Meetings with wide range of stakeholders; media work; staffengagement-Stakeholder engagement events- Publishing of key information on Trust website- Board members and exec team regularly meet staff and patients oninformal visits.- stronger contact with Leagues of Friends including Exec and NonExec links.- non execs as named links with stakeholders- recent work with Ludlow Hospital stakeholders

Controls Currently in Place to mitigate the riskCommunity links not sufficiently strong or consistent across the area,leading to low awareness of Trust or poor reputation, as a result of:

- Limited capacity in-house.- Insufficient awareness in house.- Competing interests for public/communities e.g. acute aspects of FutureFit- historical concerns at Ludlow about securing future of the communityhospital


Manager Leading on the Risk Ms Julie Thornby

MonitoringGroup

Board

1Page

FoordPJ

Typewritten text

Appendix 2


Cons Like Rating

912

633

34

2 3

Description Progress Who is responsible Due date Date Done StatusInvolvement IN CommunityFit and UCC localityworkshops

Both rounds completed forUCCs

31-Aug-2015 17-Sep-2015Peter Foord Completed

Additional meetings toengage South ShropshireStakeholders

31-Oct-2015 17-Nov-2015Ms Jan Ditheridge Completed

New approach tocommunication with Leagueof Friends

Underway 31-Dec-2015 31-Dec-2015Ms Jan Ditheridge Completed


1046Risk ID no Risk Title Policies



Where the risk applies to Nature of the riskPolicies are published on the staff Internet. Site has been updated sothat staff can more easily search for relevant policies.Formal distribution via Datix alerting system to all senior personnel.Response required for assurance that policies have been actionedPolicy on procedural documents sets out process for developmentand approval of polices.Reminders sent to authors monthly, with a summary report toDirectors detailing policies overdue for review, and policies due forreview in next 6 months

Controls Currently in Place to mitigate the riskRisk of lack of staff awareness and compliance with policies, failure oforganisation to keep policies up to dateGaps in provision of policies



MonitoringGroup

Quality and Safety Group


Cons Like Rating

615

333

25

3 1

Description Progress Who is responsible Due date Date Done StatusReview outstanding andoverdue for update policies

Reporting process to authorsand directors now wellestablished. Added tocontrols

31-Jul-2015 17-Sep-2015Peter Foord Completed


1047Risk ID no Risk Title Risk Management



Where the risk applies to Nature of the riskRisk management training is part of managers mandatory trainingprogramAwareness raising in 'Inform' and Team Brief.Directorate registersReporting to Audit CommitteeRisk Register working group reporting to Q&S Operational GroupRisk Management Policy in place.Risks discussed at Performance Review Meetings.

Controls Currently in Place to mitigate the riskLack of awareness of risks or lack of understanding of staff of how toreport and manage risks leading to harm.Failing to ensure that risks are identified and mitigated, and that risks areescalated appropriately



MonitoringGroup

Audit Committee

2Page


Cons Like Rating

915

633

35

2 3

Description Progress Who is responsible Due date Date Done StatusFurther risk forum to includeeffective escalation

Currently working withindividual managers andteam leaders to improve riskmanagement through riskassessment and teamleaders. to consider forumlater in the year

28-Feb-2016Peter Foord Pending


1048Risk ID no Risk Title Health & Safety Legislation



Where the risk applies to Nature of the riskStaff and managers awareness of requirements through training andpublicitySupport from Risk ManagerIncident reporting to highlight issuesSLA with estates for support for food, waste and environmentoperational activitiesPolicies in place or adoptedProfessional support available for HS, Estates, Security and InfectionControl

Controls Currently in Place to mitigate the riskCompliance with Health and Safety, Food, Waste and EnvironmentalLegislation



MonitoringGroup



Cons Like Rating

620

334

25

3 1

Description Progress Who is responsible Due date Date Done StatusQualitative audit of riskassessments to becompleted and fed back torisk leads

Meeting with CSMs andTeam leaders to givefeedback on H&S/riskmanagement to improveconsistency with riskmanagement. To becompleted by end Feb 16

29-Feb-2016Peter Foord In progress


1147Risk ID no Risk Title Staff Sickness



Where the risk applies to Nature of the riskPerformance management arrangements.Attendance management policyMonitoring of monthly statistics and identification of hot spots andsupport by HR team for these areasFocussed attention by operational divisions.Health and wellbeing strategy.Physiotherapy referral scheme for MSK problemsStress Policy.Manager training on management of sickness absenceQS Committee Monitor progress and deep dive where indicatedTargeted action to address areas of concernImproved flu vaccine take up

Controls Currently in Place to mitigate the riskStaff sickness trend showing signs of reducing but slowly. Areas ofespecially high sickness at times with potential for reduced quality andincreased agency use.



MonitoringGroup


3Page


Cons Like Rating

1215

933

45

3 3

Description Progress Who is responsible Due date Date Done StatusOccupational Health focuson longest term sickness

Reduction in long termabsences

30-Nov-2015 17-Nov-2015Mrs Lynne Taylor Completed

Review of best practice inother Trusts

Underway 31-Jan-2016Mrs FionaMacpherson

In progress


1223Risk ID no Risk Title Board Leadership



Where the risk applies to Nature of the riskBoard development programme with NHS Leadership AcademyExternal and Internal Board and Committee evaluationBoard member appraisalsBoard engagement with staff and stakeholdersBoard involvement in strategyBoard and Committee workplansGovernance structuresInternal audits of governance

Controls Currently in Place to mitigate the riskBoard does not assure an effective organisation with high quality, well-ledservices.



MonitoringGroup

Board


Cons Like Rating

616

434

34

2 2

Description Progress Who is responsible Due date Date Done StatusSelf assessment againstwell led standard

Assessment complete 31-Jan-2016 12-Jan-2016Ms Julie Thornby Completed

Progressing areas wherescope for improvementimprovements Board toagree actions from well ledassessment

Underway 29-Feb-2016 In progress


1717Risk ID no Risk Title Staff Appraisals



Where the risk applies to Nature of the riskTraining on appraisal process.Reports through Monthly Performance Report and discussions atrelevant meetingsSimplification of appraisal paperwork and process, after staffengagement.

Controls Currently in Place to mitigate the riskStaff do not perceive appraisals as high quality and helpful leading to:

Reduced staff motivation and contribution to Trust aims.Lack of assurance that staff are competent to undertake their roleStaff dissatisfaction and engagement reductionLack of confidence from Regulators



MonitoringGroup



Cons Like Rating

1212

633

44

3 2

Description Progress Who is responsible Due date Date Done StatusEnsure application of newsystem in largest directorate

Now a continuous process 31-Dec-2015Mr Steve Gregory In progress

Review feedback from 2015& 2016 staff surveys

31-Mar-2016 Starting for 2015


4Page

2258Risk ID no Risk Title Compliance with Equality Requirements



Where the risk applies to Nature of the riskEveryone Counts working group and thress operational leads in placeEquality Delivery System 1 completedOperational leads identifying good practice and gapsEqualities sub group of patient panelInformation required by legislation is publishedQuality and Equality Impact Assessments for service developments.Two Tick disability accreditation for HR processesEquality Policy refreshed2015Mandatory training

Controls Currently in Place to mitigate the riskRISKTrust does not meet needs of people in protected characteristics group,and they have poorer access to, experience of, Trust services.Trust does not promote equality and allows direct or indirect discriminationleading to patient or staff disadvantage, possible loss of Trust reputationand claims.



MonitoringGroup



Cons Like Rating

88

422

44

2 2

Description Progress Who is responsible Due date Date Done StatusDevelop priority areas forequality systemimprovements in discussionwith relevant service usersand community groups

Equality and diversity actionplan developed includingpriority areas and equalitiessub group of Patient Panelcommenced; fullengagement over futureplans due Spring 2016

31-May-2016Ms Julie Thornby In progress

Idenitify issues and actionimprovements in operationalservices divisions

Continuing 30-Dec-2015Mr Steve Gregory In progress

Progress EDS2 and RaceEquality Standard

31-Mar-2016Ms Julie Thornby In progress


2311Risk ID no Risk Title Lack of clarity around Organisation Targets

Area/DivisionService

Where the risk applies to Nature of the riskRegular monthly meetings are held with the TDA and the issue israised.

In the interim relevant departments are working on ‘likely’ performancethresholds to be implemented

Controls Currently in Place to mitigate the riskRISKThe TDA accountability framework sets out a range of KPIs but severallack definitions and/or performance thresholds. There is a risk that theTrust could be suddenly issued with targets that are not being achieved.CONSEQUENCETrust fails TDA targets when introduced



MonitoringGroup

Resource and PerformanceCommittee


Cons Like Rating

88

444

22

4 1

Description Progress Who is responsible Due date Date Done StatusClarify targets with TDA Written to TDA requesting

clarification. Intention iswhere definition is clear tohave local target set basedon best estimate.

31-Mar-2016Mr Steve Gregory


5Page

Register Area Finance

2316Risk ID no Risk Title Estates Compliance Issues

EstatesArea/Division

Estates ManagementService

Where the risk applies to Nature of the riskAsbestos policy was updated October 2014Sites being reviewed by contractorAssurances are being received from the contractor.Scoping and assessing against NHS premises assurance model.Program in place to inspect all buildings that are the Trustresponsibilities and were constructed pre 2000.Significant progress made with 5 year electrical testing and legionellacontrol maintenance.

Controls Currently in Place to mitigate the riskAsbestos surveys have not been recently carried , and require asbestosmanagement plans to be put into place.Risk to contractor and staff if regular inspection is not carried outLack of assurance from the Estates contractor on other complianceissues, e.g. electrical testing.

Division Finance

Manager Leading on the Risk Ms Sarah lloyd

MonitoringGroup



Cons Like Rating

612

333

24

3 1

Description Progress Who is responsible Due date Date Done StatusAscertain current position inorder to engage contractorsto carry out surveys

Position established 31-Jul-2015 10-Sep-2015Steve Lloyd Completed

Commission and completesurveys and completeremedial works

Surveys underway,Asbestos containingmaterials are beingencapsulated or removed atBridgnorth, Ludlow andWhitchurch CommunityHospitals

31-Mar-2016Steve Lloyd In progress

Set up process to implementAsbestos Action Plan

On completion of allinspections a Trust wideasbestos plan will be inplace, inspections in plan orundertaken for all propertiesmanaged be trust buildbefore 2000

31-Mar-2016Steve Lloyd Pending

Liaise with contractor toestablish position for allestates compliance issuesand action where gaps areidentified.

Work in progress 29-Feb-2016Steve Lloyd In progress


6Page

2317Risk ID no Risk Title Fire Safety Arrangements

EstatesArea/Division

Estates ManagementService

Where the risk applies to Nature of the riskNew Fire Adviser in place.Total evacuation rather than progressive evacuation at BishopsCastle, with additional staff training, and additional staffing levelsWhitchurch survey complete with minor works requiredFire risk assessments are being reviewed and updated. Completionend of Jan 16All community hospitals have been inspected by the regulatoryauthority and have been designated as broadly compliantRemedial fire stopping work are Bridgnorth and WhitchurchCommunity Hospitals is scheduled for completion end JanuaryLudlow is NHS Propco responsibility, outcome awaited.Fire drills arranged for hospitals in February

Controls Currently in Place to mitigate the riskRisk of regulatory action, fire or fire spread may be increased:Fire Risk Assessments cannot be located for all propertiesThe status of Fire Risk Action Plans is not known for all propertiesEffectiveness of fire stopping has not been reviewed in line withDH/2014/003The Trust's contracted fire adviser has retiredFire stopping survey at Bishops Castle is complete, external works(footpath) are in plan.

Division Finance

Manager Leading on the Risk Ms Sarah lloyd

MonitoringGroup



Cons Like Rating

1215

445

33

4 1

Description Progress Who is responsible Due date Date Done StatusAudit fire risk assessmentsand actions, create aregister. Carry outassessment wherenecessary

Currently in progress 29-Feb-2016Steve Lloyd In progress

Survey fire stopping andcarry out remedial work asnecessary.

Bishops Castle hospitalfurther work required hasbeen completed.Bridgnorth and Whitchurch,minor remedial works still tobe carried out.Ludlow - NHS Propco havecommissioned inspection,report awaited.

31-Jan-2016Steve Lloyd In progress

Commission arrangementsfor fire advice and support

In place 31-Aug-2015 10-Sep-2015Steve Lloyd Completed


7Page

Risk Register Report - Risks at Target Level Register Level Corporate Risk Register


956Risk ID no Risk Title Staff Engagement



Where the risk applies to Nature of the risk- Engagement work over Trust values and wider culture.- Work of Trust Leadership Group, promoting engagement with teams.- Workshops for administration staff.- Awaydays for all staff- Positive and engaged role with staff representatives. JNP meetings- Inform, team brief and CEO staff briefings.- Action plan to address issues raised by staff survey- Executive/non Executive visits- Health & wellbeing support

Controls Currently in Place to mitigate the riskNot enough, or effective enough, staff engagement processes, leading to:- Reduced quality & productivity through staff unhappiness, sicknessabsence & loss of motivation.-Missed service development opportunities through staff not being awareof business potential, based on strategies & plans.



MonitoringGroup



Cons Like Rating

616

634

24

3 2

Description Progress Who is responsible Due date Date Done StatusActions in light of staffsurvey

30-Sep-2015 17-Nov-2015Ms Jan Ditheridge Completed

Summer workshops for staffgroups

30-Sep-2015 17-Nov-2015 Completed

Team Leader Awayday Completed 31-Dec-2015 31-Dec-2015Ms Jan Ditheridge Completed


1045Risk ID no Risk Title CQC



Where the risk applies to Nature of the riskCQC program board to co-ordinate compliance activityDirectors leads for domains for each standard using CQC compliancepro forma.CQRM meetings with commissioners held monthlyRegular meetings with leads to ascertain progress against actionsReporting to Q&S and Audit CommitteesReview of regulatory process and associated action plansProcess for clinical visits and peer review to mirror principles of newCQC process.Team leader briefings

Controls Currently in Place to mitigate the riskInability to provide evidence for assurance against compliance with CQCregistration.Shortfalls in compliance identified by self assessmentShortfalls in assurance or evidence that standards are being metConcerns raised as part of compliance visitsPoor risk profile and self assessment



MonitoringGroup


1Page


Cons Like Rating

615

635

23

3 2

Description Progress Who is responsible Due date Date Done StatusPlan for CQC visits to be putinto place

Clinical peer to peer visitshave taken place andfeedback given to groups

31-Mar-2014 10-Sep-2015Dee Radford Completed

Following visits and analysisformulate and deliveractions to teams and forTrust as whole to improvecompliance.

Update 30 Dec 2015: Visitsnearly complete - action planfor Trust in place and beinguploaded to InPhase overJan/Feb. SharePoint sitebeing updated to includeactions at Trust level

31-Mar-2016 In progress


1049Risk ID no Risk Title Clinical Negligence or Third Party Litigation



Where the risk applies to Nature of the riskLegal advisorsNHSLA support with claimsLow number of claimsBeing Open PolicyLegal updates distributed to relevant managers

Controls Currently in Place to mitigate the riskClinical negligence or third party claims.Specific cases which could lead to adverse publicity or could havefinancial effects



MonitoringGroup



Cons Like Rating

69

633

23

3 2

Description Progress Who is responsible Due date Date Done Status


1051Risk ID no Risk Title SIs, other incidents



Where the risk applies to Nature of the riskSerious Incidents monitored on Datix.Root Cause Analysis carried out and action plans reviewed andsigned off by DoN or Deputy Directors, and Commissioners;Reports taken to appropriate committees.RCA challenge meetings identifies trustwide solutions andcommunicates lessons learnedAll incidents are reviewed by line managers, actions taken aredetailed, field is mandatory before incident can be approved.All incident are centrally coded and reviewed.Staff are supported at inquests to ensure coroner is given full picture,using legal support where appropriateInquest report are given to Q&S committeeQuality Matters newsletter disseminates lessons learntFreedom to speak up assessment.Duty of Candour arrangements and reportingSI reporting to Executive Team

Controls Currently in Place to mitigate the riskGeneral risk associated with clinical incidents. Specific risks raised byindividual incidents. Incidents leading to avoidable patient harm andinsufficient learning from them.Risk that incidents convert into complaints and claims



MonitoringGroup


2Page


Cons Like Rating

416

424

24

2 2



1053Risk ID no Risk Title Training and development



Where the risk applies to Nature of the riskNew core training model in place, to be reviewed annuallyCentral training databaseMonthly monitoring of performanceIntroduction of ESR Self ServiceAnnual review of mandatory training needsHCA competency based training programData analysis and reportingCompetency criteria in placeRole specific essential trainingAnnual and ongoing review of workforce development needscommissioned from external agencies.Integrated induction program in place

Controls Currently in Place to mitigate the riskGaps in provision and take up. Potential system failures. Risk of not hittingnecessary levels of mandatory training. Risk of staff not being sufficientlyaware of and prepared for assessment visits by external bodies.



MonitoringGroup



Cons Like Rating

912

933

34

3 3

Description Progress Who is responsible Due date Date Done StatusImplement integratedinduction program

Programme commencingJune 15

01-Apr-2015 20-May-2015Peter Foord Completed


1054Risk ID no Risk Title Medical Devices



Where the risk applies to Nature of the riskSafety Alerts received by the Risk Manager and escalated to serviceheads via Datix which enables monitoring and reminders to be sent.Responses and actions are logged onto the system automaticallyContract with SATH Medical Engineering Services for annualmaintenanceMedical Device Management Group convened to oversee processesMedical Device Management Policy,Verification of assets detailed by MESSafety promoted through divisional quality and safety groups

Controls Currently in Place to mitigate the riskCompliance with Safety AlertsFinancial and safety risk associated with possible inadequate and outof date register of devicesAdequacy of departmental arrangements for tracking, maintaining anddisposing of devicesCompliance with MDSO notice requirements



MonitoringGroup


3Page


Cons Like Rating

612

633

24

3 2

Description Progress Who is responsible Due date Date Done StatusRaise profile of medicaldevice management toensure that attention isgiven in a measured way toall types in use

Medical devices discussed atDivisional Quality and Safetymeetings

31-Dec-2015 Completed


1056Risk ID no Risk Title Safeguarding, including thresholds for referral



Where the risk applies to Nature of the riskSafeguarding Leads identified for Children.Deputy Director of Nursing and Quality - Operational andmanagement lead for safeguarding.Trust safeguarding meetings established.Safeguarding reported to Quality and Safety Committee.Executive Lead member on the two Local Authority Adults andChildren Safeguarding Boards.Six monthly Section 11 auditsCompliance with Safeguarding Self Assessment ToolMandatory training for staffCompliance with CQC principles

Controls Currently in Place to mitigate the riskRisk of compliance with law in relation to childrens and adultsafeguarding.Specific risks relating to incidents, concern or gaps in provision


Manager Leading on the Risk Dr Mahadeva Ganesh

MonitoringGroup



Cons Like Rating

616

634

24

3 2



1438Risk ID no Risk Title Compliance with data protection legislation



Where the risk applies to Nature of the riskInformation governance policiesIncident reporting and investigationIG training mandatory for all staffProvision of advice and supportRecords audit.Networking with IG leads to learn lessons across all public sectororganisations.Compliance with IG toolkit

Controls Currently in Place to mitigate the riskNone compliance with Data protection could lead to action by theInformation Commissioner. The level of fines has increased recently witha number of NHS organisations being fined.


Manager Leading on the Risk Ms Ros Francke

MonitoringGroup



Cons Like Rating

912

933

34

3 3



4Page

1571Risk ID no Risk Title Waiting Times



Where the risk applies to Nature of the riskRegular reporting of performance.Production of recovery plans as problems arise to address wherewaiting time exceed acceptable parameter.Data validation each monthWorking with commissioners to develop plans to address issues inlonger term.Weekly validation report to service as part of monthly reporting.

Controls Currently in Place to mitigate the riskRTT waiting times are currently being metNon RTT waiting times, Particular issues with reporting timesWaiting times are longer for some children and family servicesRTT targets have been updated following national guidance in OCT 15.APCS and MSK included in return.



MonitoringGroup



Cons Like Rating

616

624

34

2 3



Register Area Chief Executives Office

1995Risk ID no Risk Title Transformation - Staff



Where the risk applies to Nature of the riskForward workforce planning.Dialogue with commissioners and other providers identifying servicechange and associated skilling necessary.Workforce monitoring via ODW groupOD strategy and workplan.Quality Strategy.Nursing and AHP StrategyTraining statistic monitoring and actionsRole specific essential training in placeValues into Action program

Controls Currently in Place to mitigate the riskRISKSTrust does not develop staff skills to meet increased care complexity incommunity settings.Trust cannot recruit staff with additional clinical skills.

CONSEQUENCESAdditional services cannot be provided on homecare setting to meettransformation needs.

Division Chief Executives Office


MonitoringGroup



Cons Like Rating

616

634

24

3 2

Description Progress Who is responsible Due date Date Done StatusIdentify and develop rolespecific training for clinicalspecialties

TNA completed and trainingin place

30-Nov-2014 19-May-2015Peter Foord Completed

Development of clinicalcompetencies

Action completed 30-Apr-2015 13-May-2015Peter Foord Completed

Complete transformationalwork skills/competencyaudit.

Incorporated as part ofValues work

30-Apr-2015 13-May-2015Peter Foord Completed

Values into actionevaluation

Programme implementedand is active. Evaluation totake place March 2016

31-Jul-2015Mrs Sonia Orr In progress


5Page

Risk Register Report Register Level Corporate Risk Register


2492Risk ID no Risk Title Blood Glucose


Where the risk applies to Nature of the riskRegular contact and meetings with previous supplierSurvey of practice and recommendations made where improvementsare neededInvolvement of procurement

Controls Currently in Place to mitigate the riskTrust has in the past obtained blood glucose test strips, meters andQuality Assurance Solution as part of Acute contract. Acute hastransferred to a different system. Previous supplier has maintained stockon a goodwill basis. Trust needs to have a contract in place. There arechallenges with storage, distribution and other aspect of management,and additional costs are likely to be identified



MonitoringGroup



Cons Like Rating



2493Risk ID no Risk Title Lone working


Where the risk applies to Nature of the riskLone working section in Violence PolicyLocal assessment of particular risks with servicesLocal procedures, include staff whereabouts and personal detailsAll community staff have mobile phones

Controls Currently in Place to mitigate the riskRisk associated with lone working:Staff SafetyRoad safetyProfessional issuesSafety issues e.g. handling patients single handed



MonitoringGroup



Cons Like Rating



1Page

2494Risk ID no Risk Title Estates issues


Where the risk applies to Nature of the riskRegular review of registerEscalation of risks

Controls Currently in Place to mitigate the riskEstates issues can take a protracted period o time to resolve. A number ofissues have remained on divisional register for a long period, e.g.Hospital laundry's, washbasins and dental hoist.


Manager Leading on the Risk Ms Ros Francke

MonitoringGroup



Cons Like Rating



2495Risk ID no Risk Title Recruitment


Where the risk applies to Nature of the riskContingency and prioritizationControls Currently in Place to mitigate the risk

Recruitment issues regularly feature on divisional registers. These cancome from national or local shortages, time taken to place staff, or wheredisciplines have only one post. These have included:PrisonsDiabetes NursingCommunity Neuro RehabPrisonsCAMHSDental



MonitoringGroup



Cons Like Rating



2Page

Formal Board Workplan Resp.

FreqA=AnnualQ=Quarterly Jan-16 Mar-16 May-16 Jul-16 Sep-16 Nov-16

Chairmans Report CHAIRReport from NEDs visits NEDsCEOs Report CEOPatient Story DoN&OQuality and Safety Report DoNFinance and Performance Report DoFGovernance Report including BAF DoCASafer Staffing Report DoN&OCommittee minutes DoCA

Planning Cycle Finance Report DoF x x xEnd of year finance and performance DoF A x x xAnnual Plan DoF x x xBudget setting DoF A x x xPlanning framework DoS A x x x x xTrust Annual Plan - public version,divisional business plans DoS A x x x x x

Emergency Planning and BusinessContinuity Annual Report DoN&O A x x x x x

Health and Safety Annual Report DoCA A x x x x xDeclaration of Interests DoCA A x x x x xCode of Conduct DoCA A x x x x x

Adoption of Annual Report and Accounts DoS/DoF A x x x x x

Transformational update, includingBusiness Development DoN&O As req.

Complaints/PALs Annual Report DoN&O A x x x x xInfection Prevention and Control AnnualReport DoN&O A x x x x x

Safeguarding Adults Annual Report DoN&O A x x x x xSafeguarding Children Annual Report DoN&O A x x x x xCQC Registration compliance report DoN&O A x x x x xQuality Account DoN&O A x x x x xDeclaration of Single SexAccommodation provision DoN&O x x x x

Surge and Capacity Management,including winter planning DoN&O A

x Delivery report

x xPlan

x

Medical Re-validation Med Dir A x x x x xMonitor Well-Led Framework DoCA A x x x x xHospitality Report DoCA x x x x xUse of Trust seal DoCA x x x

Urgent Extras All As req.

Potential Items

CH ChairCEO Chief ExecutiveMed Dir Medical DirectorDoN&O Director of Nursing andOperationsDoF Director of FinanceDoS Director of StrategyDoCA Director of Corporate Affairs

Shropshire Community Health NHS Trust

Ad Hoc Reports

Standing Items (all meetings)

Periodical Reports

FoordPJ

Typewritten text

Appendix 3

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Appendix 4

Shropshire Community Health NHS Trust

Hospitality Register: 1 June 2014 to 31 May 2015

1. Introduction

Shropshire Community Health NHS Trust Standing Orders require that a Register ofHospitality/Gifts is established. This is in line with guidance contained in the Standards ofBusiness Conduct for NHS Staff (Appendix to SOs), the Code of Conduct for NHSManagers, and the ABPI Code of Professional Conduct relating to hospitality/gifts frompharmaceutical/external industry.

The rationale for having the register of hospitality/gifts and asking staff to openly identify anygifts or hospitality they have been offered or accepted is to ensure staff are not placed in aposition of compromise or risk because of accepting any gifts which could be construed asan inducement. Public sector bodies must be impartial and honest in the conduct of theirbusiness. It is an offence for an employee to accept any inducement or reward for doing, orrefraining from doing, anything in their official capacity or showing favour, or disfavour, in thehandling of contracts. Staff must ensure they do not abuse their position for personal gainor for the benefit of their families or friends.

The principles are set out in the Trust’s Code of Business Conduct for Trust staff. The TrustCode states that staff must declare and register any gifts, benefits or sponsorship of anykind - provided they are worth at least £25 – and any offers of hospitality, whether refused oraccepted.

Articles of low intrinsic value, such as diaries, calendars or small tokens of gratitude frompatients or their relatives (eg chocolates, flowers) do not need to be registered. However, ifthe hospitality/gifts were from the same individuals over a short period of time, thecumulative worth could become more significant and require registration.

Under the Code, modest hospitality, provided it is reasonable in the circumstances andsimilar to the scale of hospitality which the NHS as an employer is likely to provide, isacceptable.

The Code and what it means for staff has been publicised to Trust staff in ‘Inform’ the staffnewsletter and in Team Brief, and the Code is on the Trust zone of the web site with otherpolicies. The Code and supporting publicity stress that if staff are unsure of whether theyneed to declare, they should seek advice from their line manager or the Director ofCorporate Affairs.

2. Summary of Hospitality Register

Below is a summary, by Directorate, of each entry received for the Hospitality Registerbetween 1 June 2014 – 31 May 2015 detailing offers which were accepted. There havebeen no notifications of offers of sponsorship/gifts etc which were made but not accepted.Each entry is submitted for review and sign off by the individual’s manager, and then by theDirector of Corporate Affairs before being entered in the Register.

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3a. Operations Directorate

Date andAmount ofHospitality,Gift orSponsorship

From To For(plus any additionalcomments by recipients)

Date ofRegisterProforma

Jan 2014£465

Sanofi RebeccaLennon,DiabetesSpecialist Nurse

Sponsorship offered forDiabetes UK NationalConference X3 daysMarch 2014.Overnight accommodationX2 nights with eveningmeal.

17.6.14

28.1.14£465

Sanofi Angela Cook,DiabetesSpecialist NurseManager

Educational sponsorshipfrom Sanofi to attendDiabetes UK AnnualProfessional Conference.Accommodation & trainfare in Liverpool 5-7th

March 2014.

17.6.14

5.3.14 -7.3.14£465

Sanofi Christine Parry,DiabetesSpecialist Nurse

Sponsorship of place atDiabetes UK Conference2014 & accommodation.Offered Sponsorship.

17.6.14

23.5.14£10

Patient Group atthe end of theirProgramme

Kim Brown,Physiotherapist

£10 Boots token. 4.7.14

15.10.14£355

JanssenPharmaceutical

CommunityDiabetesNursing Service

Supporting educationalevent certificate inDiabetes Care (WarwickCourse).Actively sought fromJanssen, for delegates oncourse.

27.10.14

1.12.14£100

Mrs Mary Vernan AndrewThomas, ClinicalServicesManager

5X £20 vouchers forNorthwood HallRestaurant from patientrecently treated at thehospital.5 names to be drawn outof hat from WhitchurchHospital Staff.

12.12.14

2.12.14£130

Mr StephenCharteris

Jacqui Phillips,DiabetesSpecialist Nurse

Portable 15.6” HD DigitalLCD TV/DVD.Donated by a member ofBridgnorth Rotary Club forthe use in delivery of XpertDiabetes Programme to

16.1.15

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patients in communitysettings. Following a talkto Rotary Club aboutDiabetes.

3.2.15£367

Takeda CassandraRicchiuti,DiabetesSpecialistDietician

Takeda Sponsorship forattendance at DiabetesUK.

17.4.15

3.3.15 SBCommunications &Janssen

Cate Davies,CommunityDiabetes Nurse

Practical Management ofType 2 Diabetes; targetingthe body while engagingthe mind.1 day course held atBirmingham Metropolehotel.

29.4.15

3.3.15£100

Johnson &Johnson

Holly Jannikos,Diabetes Nurse

Practical management ofType 2 Diabetes; targetingthe body & mind.

17.4.15

11.3.15 &12.3.15£500

Takeda Danella Smith,DiabetesSpecialist Nurse

Sponsorship for DiabetesUK and hotelaccommodation.Rail fare & tube fare.

24.4.15

3b. Trust Board

18.5.15£35

Mills & ReeveSolicitors

Steve Gregory,Director ofNursing andOperations

Dinner during NHSConfederation ConferenceThursday 4th June 2015.Blakes Restaurant,Central Building, NorthJohn Street, Liverpool, L26RR.

5.6.15

18.5.15£35


Jan Ditheridge,Chief Executive

Dinner during NHSConfederation ConferenceThursday 4th June 2015.Blakes Restaurant,Central Building, NorthJohn Street, Liverpool, L26RR.

5.6.15

18.5.15£35


Mike Ridley,Chairman

Dinner during NHSConfederation ConferenceThursday 4th June 2015.Matov Pan AsianRestaurant GeorgePierhead, Liverpool, L31EY

19.9.15

18.5.15£35


Mike Ridley,Chairman

Dinner during NHSConfederation ConferenceThursday 3rd June 2015.Restaurant Bar and GrillHalifax House, Brunswick

19.9.15

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Street, Liverpool, L2 0UU

3c. Corporate Affairs Directorate

None

3d. Finance Directorate

None

3e. Nursing Directorate

None

3f. Medical Directorate

None

4. Breakdown by Category

The following is a breakdown of entries for the last year by category. They have beenbroken down into 5 general categories, with the number of entries and estimated value.However, it should be noted that the estimated value of some entries is not given, or notknown, for example when the hospitality/event was paid for directly by the sponsor.

For comparison purposes:

2014/15

15 entries

Sponsorship by Pharmaceutical Company for or towards costs ofhospitality, venues, workshops, clinical governance meetings, events,training, info packs, etc for groups of staff or awareness raising withpublic

1£355

Sponsorship or hospitality by Pharmaceutical or other Company toan individual member of staff eg lunch, dinner, gifts (memory stick,books, etc)

4£140

Sponsorship (by Pharmaceutical or other Company) to an individualmember of staff for conference costs, travel outside UK, etc

UK – 7£2,362

Non-UK – Nil

Gifts from patients/carers (generally small intrinsic value eg flowers,chocolates, wine, toiletries)

6£110

Sponsorship/gifts from patients/carers valued at over £25 1£130

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2013/14 21 entries, value £3,260 2014/15 15 entries, value £3,097

5. Recommendations

That the Board formally notes the report on the entries in the Hospitality Registerbetween 1 June 2014 and 31 May 2015.

That the Executive Team continues to remind Managers and staff of the principles inthe Trust’s Code of Conduct and the need to declare offers of gifts and hospitality inline with it.

Meeting Date: 28th January 2016 SUMMARY REPORT Agenda … · The BAF and Corporate Risk Registers...

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