Risk Register Report V2 - NHS Foundation Trust...RISK REGISTER 01. Corporate / Organisational Risk...
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RISK REGISTER 01. Corporate / Organisational Jennifer Boyle Yvonne Ormston Risk Assessor Risk Owner Risk Reference Version Date Identified CE11 16 15/10/2015 Status Ongoing Risk Details Description Ability to achieve adequate NHS Improvement compliance in challenging times in accordance with the requirements of the Single Oversight Framework (quality, performance, finance, well-led and strategic progress). Impact Potential for regulatory action, particularly in relation to our financial position and subsequent risk rating under the new Single Oversight Framework, given our control total and operational performance. 5 Likelihood 4 Severity Score 20 Initial Risk Rating Controls in Place Details of Control Regular financial monitoring at the Board and Finance Committee, which informs our monthly and quarterly submissions compliance to NHSI. The plan for 17/18 predicts a use of resources score of 3 (out of 4 with 4 being the worst score), meaning that the Trust would receive mandated support from NHSI, resulting from significant concerns. Gaps in Control Effectiveness Some Weakness Details of Control Monthly monitoring of our performance targets at the Board (except August and December), which contribute towards our quarterly NHSI returns. Performance is currently very challenged and therefore there is a potential that we may be placed in segments 3 or 4 from a performance perspective under the Single Oversight Framework. Gaps in Control Effectiveness Some Weakness Details of Control Emergency Care Performance Recovery Plan in place and assurance sought at every Board meeting that the plan is being implemented. Performance recovery plan no longer presented at Board - a new plan is in development. Gaps in Control Effectiveness Inadequate Details of Control Delivering Consistently meetings have been reformatted and are held monthly to seek assurance from service lines that all aspects of performance are being effectively managed. The format of the meetings will need to be revised following the organisational restructure Gaps in Control Effectiveness Inadequate Details of Control Board has been appraised of the new Single Oversight Framework and the implications for our ratings. Governors have also been informed. Quarterly meetings are held with NHSI to discuss the outcome and segment scoring. No identified gaps - regular monitoring is in place. Gaps in Control Effectiveness Satisfactory Details of Control Controls in place to measure quality - with regular reporting to the Quality Committee and Board Safer staffing report is in development. There is a need to ensure appropriate mapping of CQC standards to Board and committees - a plan is in place. Gaps in Control Effectiveness Some Weakness 4 3 Score Severity Likelihood 12 Residual Risk Rating Date Printed: 17/10/2017 Page 1 of 21 ULY301 - Risk Register Report V2
Transcript of Risk Register Report V2 - NHS Foundation Trust...RISK REGISTER 01. Corporate / Organisational Risk...
RISK REGISTER
01. Corporate / Organisational
Jennifer BoyleYvonne Ormston Risk AssessorRisk Owner
Risk Reference Version Date IdentifiedCE11 16 15/10/2015 Status Ongoing
Risk Details
Description Ability to achieve adequate NHS Improvement compliance in challenging times in accordance with therequirements of the Single Oversight Framework (quality, performance, finance, well-led and strategic progress).
Impact Potential for regulatory action, particularly in relation to our financial position and subsequent risk rating under thenew Single Oversight Framework, given our control total and operational performance.
5Likelihood 4Severity Score 20
Initial Risk Rating
Controls in Place
Details of Control Regular financial monitoring at the Board and Finance Committee, which informs our monthly and quarterlysubmissions compliance to NHSI.
The plan for 17/18 predicts a use of resources score of 3 (out of 4 with 4 being the worst score), meaning that theTrust would receive mandated support from NHSI, resulting from significant concerns.
Gaps in Control
Effectiveness Some Weakness
Details of Control Monthly monitoring of our performance targets at the Board (except August and December), which contributetowards our quarterly NHSI returns.
Performance is currently very challenged and therefore there is a potential that we may be placed in segments 3or 4 from a performance perspective under the Single Oversight Framework.
Gaps in Control
Effectiveness Some Weakness
Details of Control Emergency Care Performance Recovery Plan in place and assurance sought at every Board meeting that theplan is being implemented.
Performance recovery plan no longer presented at Board - a new plan is in development.Gaps in Control
Effectiveness Inadequate
Details of Control Delivering Consistently meetings have been reformatted and are held monthly to seek assurance from servicelines that all aspects of performance are being effectively managed.
The format of the meetings will need to be revised following the organisational restructureGaps in Control
Effectiveness Inadequate
Details of Control Board has been appraised of the new Single Oversight Framework and the implications for our ratings.Governors have also been informed.Quarterly meetings are held with NHSI to discuss the outcome and segment scoring.
No identified gaps - regular monitoring is in place.Gaps in Control
Effectiveness Satisfactory
Details of Control Controls in place to measure quality - with regular reporting to the Quality Committee and Board
Safer staffing report is in development.There is a need to ensure appropriate mapping of CQC standards to Board and committees - a plan is in place.
Gaps in Control
Effectiveness Some Weakness
43 ScoreSeverityLikelihood 12
Residual Risk Rating
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Actions
Target Date2No. 31/10/2017 Completed DateGraham TebbuttResponsible for Action / /
Action Description Delivering Consistently meetings aligned to the Trust's old service line structure. There will be a need to reformatthese once Phase 1 of the restructure is completed.
Progress new performance manage,ment framework being implemented which will feed back to the DeliveringConsistently meeting
Date Entered : 22/08/2017 10:25Entered By : Graham Tebbutt -----------Delivering Consistently is being remodelled by G Tebbutt and team, alongside the operational servicesperformance meetings. This is to ensure appropriate alignment under the new structure. A draft structure hasbeen presented to ET for review.
Date Entered : 08/08/2017 08:38Entered By : Jennifer Boyle
Outcome Details Awaiting Further Act
Target Date3No. 31/10/2017 Completed DateGraham TebbuttResponsible for Action / /
Action Description A need to develop a new performance framework for the services.
Progress Work has commenced with input from the Deputy COO.
Date Entered : 19/05/2017 14:24Entered By : Jennifer Boyle
Outcome Details
Target Date4No. 31/10/2017 Completed DateJoanne BaxterResponsible for Action / /
Action Description To ensure that ongoing monitoring of CQC KLOEs / standards are mapped to Board and committees /governance structures to inform CoB etc.
Progress The deadline was Friday 11th August for chairs to review the lists against their ToR and CoB. Most responseshave been received at this point and are being collated. Once all responses are received all associated gaps willbe pulled into an action plan for circulation, sign off and ongoing monitoring.
Date Entered : 21/08/2017 15:01Entered By : Stevie Mcaskell -----------Time out day completed, further day planned to close out the work on 27th June 2017
Date Entered : 27/06/2017 15:40Entered By : Joanne Baxter -----------Work commenced.A time-out day is planned for the beginning of June to fully complete this work.
Date Entered : 19/05/2017 14:27Entered By : Jennifer Boyle
Outcome Details Awaiting Further Act
2 3 ScoreSeverityLikelihood 6
Target Risk Rating
29/09/2017
ReviewFrequency
Reviewed By ReviewDate
Review DetailsLastReviewDate
Jennifer Boyle Risk reviewed and updated 29/09/2017Monthy
Reviews
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Jennifer Boyle Risk fully updated to reflect progress made in respect of DeliveringConsistently and the Performance Improvement Plan
08/08/2017
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01. Corporate / Organisational
Paul LiversidgePaul Liversidge Risk AssessorRisk Owner
Risk Reference Version Date IdentifiedORR-41 3 13/10/2015 Status Ongoing
Risk Details
Description Failure to deliver all Ambulance KPI's in relation to response times, red calls and long waits for G calls increase
Impact Patient safety and financial penalties applied. reputational risks/damage to the trust
4Likelihood 5Severity Score 20
Initial Risk Rating
Controls in Place
Details of Control Performance improvement action plan
External factors relating to increased handover delays and increased number of divertsGaps in Control
Effectiveness Uncertain
Details of Control Twice weekly performance meeting
Representation can sometime be unsatisfactoryGaps in Control
Effectiveness Some Weakness
Details of Control Board reports (including performance report)
NoneGaps in Control
Effectiveness Satisfactory
Details of Control Delivering consistently and service line meetings
Attendance is sometimes poorGaps in Control
Effectiveness Some Weakness
Details of Control Daily performance report electronically sent out to operations and others
NoneGaps in Control
Effectiveness Satisfactory
Details of Control Transformation projects
short term resultsGaps in Control
Effectiveness Adequate
Details of Control External scrutiny to review our improvement plans and offer further advice on improvement initiatives
The ability to achieve performance with the staffing we have available on the dayGaps in Control
Effectiveness Adequate
Details of Control Weekly HR provisions meetings held in all three Divisions, attendance management is a standing agenda item.New attendance management policy introduced.
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High level of MSC injuries, high number ofstaff on Long Term SickGaps in Control
Effectiveness Some Weakness
Details of Control Regular commissioning meetings and discussions
Commissioners understanding of the reasons why NEAS are unable to achive an improvement in response timesfor all calls.
Gaps in Control
Effectiveness Some Weakness
Details of Control Daily 13.00hrs conference calls to be introduced to review staffing Mon-Fri. RSD to produce reports for thefornight ahead including detail of abstractions.
Relies on availability and abstractions/staffing can change at short notice.Gaps in Control
Effectiveness Some Weakness
Details of Control workforce plan and the review thereof through our internal Governance arrangements
A profession at risk - availability of ParamedicsGaps in Control
Effectiveness Satisfactory
Details of Control Full implementation of the Ambulance Response Programme will reduce the numbers of calls categorised as Red
Inability to triage healthcare professional callsGaps in Control
Effectiveness Adequate
Details of Control Organisation restructure
The speed of implementation and embedding new staffGaps in Control
Effectiveness Satisfactory
Details of Control Demand and capacity review commissioned by ORH
Depending on the outcome no investmentGaps in Control
Effectiveness Adequate
Details of Control Introduction of the ambulance response programme (ARP)
Outcome of the introduction of ARP not well knownGaps in Control
Effectiveness Satisfactory
44 ScoreSeverityLikelihood 16
Residual Risk Rating
Actions
Target Date9No. 31/03/2017 Completed DateResponsible for Action 14/10/2016
Action Description Work continues both internally and externally to recruit to vacancies, reduce abstractions, improve downtime andreduce handover delays.
Progress
Outcome Details Closed
Target Date8No. 01/04/2017 Completed DatePaul LiversidgeResponsible for Action 03/04/2017
Action Description Continue to discuss with commissioners the current situation in respect of NEAS's operational situation to seekongoing investment to improve response times
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Progress Investment recieved for 2017/18
Date Entered : 03/04/2017 10:57Entered By : Paul Liversidge -----------On-going discussions with commissioners relating to service provision.
Date Entered : 14/10/2016 09:20Entered By : Paul Liversidge -----------A EC recovery plan has been shared with Commissioners along with an agreed performance trajectory
Date Entered : 25/07/2016 08:02Entered By : Paul Liversidge
Outcome Details Closed
Target Date16No. 25/12/2017 Completed DatePaul LiversidgeResponsible for Action / /
Action Description Report the outcome of the demand and capacity review
Progress
Outcome Details
Target Date10No. 31/03/2017 Completed DateResponsible for Action 14/10/2016
Action Description Improved initiatives to identify staffing shortfalls to be introduced from 11-7-16
Progress
Outcome Details Closed
Target Date17No. 30/11/2017 Completed DatePaul LiversidgeResponsible for Action / /
Action Description Introduce the actions of the ambulance response programme
Progress
Outcome Details
Target Date18No. 21/09/2017 Completed DateVictoria CourtResponsible for Action 21/09/2017
Action Description Prioritise the performance improvement plan to identify those actions that provide the biggest impact
Progress Complete
Date Entered : 21/09/2017 07:42Entered By : Paul Liversidge
Outcome Details Closed
Target Date6No. 30/06/2017 Completed DateDavid SoreResponsible for Action 03/04/2017
Action Description Review current improvment plan and make reference to the recent red rate workshop action planning day.Include all actions from the external scrutiny event.
Progress Red rate idntified in all reviews.
Date Entered : 03/04/2017 10:58Entered By : Paul Liversidge -----------All plans being reviewed and monitored
Date Entered : 14/10/2016 09:22Entered By : Paul Liversidge -----------recovery plans being monitored against an agreed trajectory
Date Entered : 19/07/2016 08:27Entered By : Paul Liversidge -----------
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Action plans now available and being monitored against an externally trajectory.
Date Entered : 19/07/2016 08:23Entered By : Paul Liversidge -----------The previous action plans are still being revised into a new, updated action plan, taking into account past action,actions from the AACE visit and referencing the Red rate workshop actions.
Date Entered : 25/04/2016 14:30Entered By : David Sore
Outcome Details Closed
Target Date3No. 01/09/2016 Completed DateDouglas McdougallResponsible for Action 19/07/2016
Action Description Improved efficiency initiatives to improve productivity, manage sickness absence to the policy, reduce downtime,ensure staffing is maximised at all times, challenge poor performance etc
Progress Target is to reduce downtime by 20% by September
Date Entered : 19/07/2016 08:28Entered By : Paul Liversidge -----------Working with CCDFT to improve handover times. EC Management meeting on 23rd June 2016 to map out andimplement ORH recomendations Attendance management remains a high priority
Date Entered : 20/06/2016 11:22Entered By : Douglas Mcdougall -----------Target date changed due to changes to absence policy. Monthly meetings with Ops Managers with the agendato include Attendance, Productivity and downtime.
Date Entered : 27/11/2015 10:22Entered By : Douglas Mcdougall
Outcome Details Closed
Target Date4No. 31/05/2017 Completed DateGary MolloyResponsible for Action 03/04/2017
Action Description Improved efficiency initiatives to improve productivity, manage sickness absence to the policy, reduce downtime,ensure staffing is maximised at all times, challenge poor peformance etc
Progress 10% gain achieved.
Date Entered : 03/04/2017 10:59Entered By : Paul Liversidge -----------Review of downtime states a 10% reduction on last year however a review is required to separate positivedowntime.
Date Entered : 14/10/2016 09:21Entered By : Paul Liversidge -----------Target is 20% reduction by September 2016
Date Entered : 19/07/2016 08:25Entered By : Paul Liversidge -----------Ongoing analysis and action relating to improving downtime and efficiency
Date Entered : 19/07/2016 08:24Entered By : Paul Liversidge -----------This is ongoing work to improve efficiency
Date Entered : 01/04/2016 15:27Entered By : Paul Liversidge -----------On going work
Date Entered : 15/02/2016 22:02Entered By : Paul Liversidge
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Outcome Details Closed
Target Date5No. 30/06/2017 Completed DateElaine BenningtonResponsible for Action 03/04/2017
Action Description Improved efficiency initiatives to improve productivity, manage sickness absence to the policy, reduce downtime,ensure staffing is maximised at all times, challenge poor peformance etc.
Progress Ongoinbg
Date Entered : 03/04/2017 11:00Entered By : Paul Liversidge -----------The above actions continue along with commissioner discussions regarding handover delays and hospitalcapacity issues, an increase in VAS and specific projects under 'Transformation'.
Date Entered : 13/01/2016 11:17Entered By : Elaine Bennington
Outcome Details Closed
Target Date14No. 30/04/2018 Completed DateVictoria CourtResponsible for Action 23/05/2017
Action Description Implement the actions of the performance improvement plan
Progress Work ongoing to implement the actions
Date Entered : 23/05/2017 10:54Entered By : Paul Liversidge
Outcome Details Closed
Target Date15No. 31/07/2017 Completed DateVictoria CourtResponsible for Action 23/05/2017
Action Description Consider the best use of the investment from Commissioners this year to maximise performance improvement
Progress initiatives and plans being considered.
Date Entered : 23/05/2017 10:58Entered By : Paul Liversidge
Outcome Details Closed
Target Date11No. 01/08/2017 Completed DateKaren ForsythResponsible for Action 15/05/2017
Action Description Workforce plan receives scrutiny through the internal Governance arrangements of the Trust
Progress Workforce plan is being reviewed
Date Entered : 15/05/2017 12:43Entered By : Paul Liversidge
Outcome Details Closed
Target Date7No. 30/06/2017 Completed DateKaren ForsythResponsible for Action 03/04/2017
Action Description External recruitment of Paramedics, both nationally and Internationally to increase Paramedic Numbers
Progress Plans in place to progress another recruitment drive
Date Entered : 03/04/2017 10:57Entered By : Paul Liversidge -----------Expected to be very close to full Paramedic establishment by April 2017
Date Entered : 14/10/2016 09:17Entered By : Paul Liversidge -----------A number of external Paramedics have been recruited, a number of Paramedics from Poland have beenrecruited.
Date Entered : 04/04/2016 15:40Entered By : Douglas Mcdougall
Outcome Details Closed
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Target Date12No. 03/07/2017 Completed DatePaul LiversidgeResponsible for Action 15/05/2017
Action Description Continue to be a pilot site for the ambulance response programme and try and influence the national projectteam to allow us to be the next NHSP pilot site for the new coding.
Progress Awaiting further information from the national project team
Date Entered : 15/05/2017 12:48Entered By : Paul Liversidge
Outcome Details Closed
Target Date13No. 31/08/2017 Completed DatePaul LiversidgeResponsible for Action 15/05/2017
Action Description Introduce the agreed restructure of the organisation
Progress Phase 1 concluding and now moving to phase 2
Date Entered : 15/05/2017 12:54Entered By : Paul Liversidge
Outcome Details Closed
2 4 ScoreSeverityLikelihood 8
Target Risk Rating
22/08/2017
ReviewFrequency
Reviewed By ReviewDate
Review DetailsLastReviewDate
Paul Liversidge Reviewed and updated 22/08/2017
Paul Liversidge Reviewed and updated 23/05/2017
Paul Liversidge Reviewed and updated 03/04/2017
Paul Liversidge agreement reached with Commissioners on our timescale for agreeing tomeet standards. This is based on this years agreement.
16/01/2017
Paul Liversidge Reviewed 16/12/2016
Paul Liversidge Reviewed 14/11/2016
Paul Liversidge Reviewed and updated 14/10/2016
Paul Liversidge Reviewed and still relevant 28/09/2016
Paul Liversidge Reviewed and still on-going, no change. 18/08/2016
Paul Liversidge Reviewed and all controls and actions still relevant 18/07/2016
Paul Liversidge Reviewed and added a control and an action. 14/06/2016
Paul Liversidge Reviewed and updated 01/04/2016
Paul Liversidge I am assured by the action being taken 13/11/2015
Quarterly
Reviews
Date Printed: 17/10/2017 Page 9 of 21ULY301 - Risk Register Report V2
RISK REGISTER
01. Corporate / Organisational
Caroline ThurlbeckGraham Tebbutt Risk AssessorRisk Owner
Risk Reference Version Date IdentifiedORR-45 5 21/09/2016 Status Ongoing
Risk Details
Description System change. The NHS and social care economy in the North East is undertaking Sustainability andTransformation Planning, local authorities are exploring devolution and North Tyneside and Northumberland arelooking to develop accountable care organisations (ACOs).
Impact System reconfiguration has the potential to impact across the organisation on performance and quality, resourcesand finances.
4Likelihood 4Severity Score 16
Initial Risk Rating
Controls in Place
Details of Control Director and Snr Mgt engagement with STP development for both NTW and North Durham and Darlington andTees
STP governance arrangements are still being developedGaps in Control
Effectiveness Satisfactory
Details of Control Director and Snr Mgt engagement in ACO development
Proposals are still in developmentGaps in Control
Effectiveness Satisfactory
Details of Control Director engagement in NECA and Health and Social Care Commission work
As devolution in the North of the patch will not be progressing at this point there is work to be done across thehealth and social care economy to ensure that the recommendations of the Health and Social Care Commissionare taken forward.
Gaps in Control
Effectiveness Some Weakness
Details of Control NEAS have undertaken internal modelling and have supported the modelling work being undertaken by theSouth STP.
Modelling work needs to be extended to the North STP.A revised reconfiguration has been developed for the South - new modelling needs to take place for both STPsectors.
Gaps in Control
Effectiveness Satisfactory
Details of Control A regional STP comms group has been established and Mark Cotton is representing the trust
internal communications plan to be developedGaps in Control
Effectiveness Satisfactory
Details of Control North Tyneside ACO put on hold as a result of organisation going in to special measures
NoneGaps in Control
Effectiveness Adequate
43 ScoreSeverityLikelihood 12
Residual Risk Rating
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Actions
Target Date1No. 31/03/2018 Completed DateCaroline ThurlbeckResponsible for Action / /
Action Description Continue engagement in STP work streams
Progress
Outcome Details
Target Date2No. 30/06/2017 Completed DateLynne HodgsonResponsible for Action / /
Action Description Continue engagement in ACO work streams
Progress
Outcome Details
Target Date3No. 30/06/2017 Completed DateResponsible for Action / /
Action Description Maintain watching brief on Local Authority Devolution
Progress
Outcome Details
3 3 ScoreSeverityLikelihood 9
Target Risk Rating
19/07/2017
ReviewFrequency
Reviewed By ReviewDate
Review DetailsLastReviewDate
Lynne Hodgson Still awaiting outcome of review by NHSI and NHSE on ACO businesscase fro Northumberland. Consideration being made re implications ofsystem wide ACS across the Northern Region
19/07/2017
Caroline Thurlbeck ACO in Northumberland proceeding to business case. STP for DDTHRWprogressing to preconsultation business case. STP for NTW and NorthDurham proceeding. Devolution for NTW not proceeding in original form- some LAs looking to progress. The Trust remains linking into coremeetings and workstreams.
03/04/2017
Quarterly
Reviews
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01. Corporate / Organisational
Mathew BeattiePaul Aitken-Fell Risk AssessorRisk Owner
Risk Reference Version Date IdentifiedORR-46 5 10/11/2016 Status Ongoing
Risk Details
Description The challenges of meeting the Trusts key performance indicators regarding ambulance response times isresulting in a number of long ambulance delays. In order to review safety of those patients who have experienceda delay, it would be best practice to carry out an audit to determine harm if any and therefore support incidentreporting and learning. However the current resources in the clinical audit team doe not support any activity otherthan the mandated AQI's.
Impact Any potential harm to patients is not readily identified
4Likelihood 4Severity Score 16
Initial Risk Rating
Controls in Place
Details of Control incident reporting - work on-going to improve incident reporting which would trigger an investigation and clinicalreview
Incident reporting needs to improveGaps in Control
Effectiveness Some Weakness
Details of Control Complaints - complaints are assessed against potential and actual harm and reported as an incident if so andclinical review and investigation occurs
reliant on patient and relative complainingGaps in Control
Effectiveness Some Weakness
Details of Control Health care professional forms and SIRMS reporting - incidents from other health care professional on careafforded or delays experienced are reported - therefore clinical review and investigation undertakenagain reliant on external measures to identify potential or actual harmGaps in Control
Effectiveness Some Weakness
Details of Control red delays audit in place and reported to CEG
no regular audit for wider ambulance delaysGaps in Control
Effectiveness Satisfactory
44 ScoreSeverityLikelihood 16
Residual Risk Rating
Actions
Target Date5No. 10/09/2017 Completed DatePaul Aitken-FellResponsible for Action / /
Action Description business case being drafted to present to ET for additional staffing for this audit to be undertaken
Progress Business case complete now to be submitted to ET
Date Entered : 05/10/2017 12:31Entered By : Paul Aitken-Fell
Outcome Details Awaiting Further Act
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Target Date2No. 31/05/2017 Completed DatePaul Aitken-FellResponsible for Action / /
Action Description work with Audit committee chair to determine audit plan for 17/18 linked to clinical risk areas.
Progress undertaking work on identifying gaps
Date Entered : 03/05/2017 15:35Entered By : Paul Aitken-Fell -----------Work on going
Date Entered : 14/02/2017 16:45Entered By : Paul Aitken-Fell
Outcome Details
Target Date4No. 31/07/2017 Completed DateResponsible for Action / /
Action Description on going as part of phase 2 restructure
Progress
Outcome Details
Target Date1No. 01/06/2017 Completed DatePaul Aitken-FellResponsible for Action / /
Action Description Identify resources required for clinical audit team to carry out a statistically appropriate sample to auditambulance delays and identify any potential harm
Progress work ongoing
Date Entered : 14/02/2017 16:45Entered By : Paul Aitken-Fell
Outcome Details
3 2 ScoreSeverityLikelihood 6
Target Risk Rating
05/10/2017
ReviewFrequency
Reviewed By ReviewDate
Review DetailsLastReviewDate
Paul Aitken-Fell Risk remains unchanged due to delays with recruitment associated withrestructure. Work is however ongoing to mitigate ambulance delays.Business case has been completed and is to be submitted to ET
05/10/2017
Alan Gallagher Risk remains unchanged due to delays with recruitment associated withrestructure. Work is however ongoing to mitigate ambulance delays.
04/08/2017
Joanne Baxter clinical audit plan being reviewed to identify resource required.temporary audit capacity being explored
22/03/2017
Monthy
Reviews
Date Printed: 17/10/2017 Page 13 of 21ULY301 - Risk Register Report V2
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01. Corporate / Organisational
Lynne HodgsonDuncan Sellers Risk AssessorRisk Owner
Risk Reference Version Date IdentifiedORR-49 4 18/05/2017 Status Ongoing
Risk Details
Description Inability to achieve challenging CIP target for 2017/18
Impact - Significant detrimental effect on financial sustainability - Negative impact on financial use of resources score, which may lead to regulatory intervention - Over-reliance on non-recurrent savings leading to an even more challenging target for 2018/19
5Likelihood 4Severity Score 20
Initial Risk Rating
Controls in Place
Details of Control Monthly CIP and budget meetings in place
Budget holders do not always manage within the agreed planGaps in Control
Effectiveness Some Weakness
Details of Control CIP mitigation list in place, with dedicated CIP meetings being held during the year with Directors and seniormanagers
CIPs harder to identify and deliver given the volume of savings being made from small initiatives in previousyears
Gaps in Control
Effectiveness Adequate
Details of Control Transformation schemes developed to deliver longer term recurrent savings
Insufficient control over delivery of transformational project timelines, impacting upon the delivery of the CIPGaps in Control
Effectiveness Some Weakness
Details of Control Monthly CIP reporting to the Transformation Board, Finance Committee, Trust Board and NHSI
Need to develop internal reporting to support the newly restructured Directorates and in particular the managersnot in attendance at Transformation Board meetings.
Gaps in Control
Effectiveness Some Weakness
44 ScoreSeverityLikelihood 16
Residual Risk Rating
16/10/2017
ReviewFrequency
Reviewed By ReviewDate
Review DetailsLastReviewDate
Duncan Sellers Score unchanged, although the FOT has now reduced to £5.7m (@ M06). 16/10/2017
Duncan Sellers Score unchanged, although the FOT has improved by £0.6m to £6.6m @M05 v £7.6m plan.
15/09/2017
Duncan Sellers Score unchanged, although the FOT has reduced by £0.38m since M03. 16/08/2017
Duncan Sellers Score unchanged, although the size of the gap between plan andforecast outturn has reduced since last month.
21/07/2017
Monthy
Reviews
Date Printed: 17/10/2017 Page 14 of 21ULY301 - Risk Register Report V2
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01. Corporate / Organisational
Lynne HodgsonMark Redhead Risk AssessorRisk Owner
Risk Reference Version Date IdentifiedORR-50 2 18/05/2017 Status Ongoing
Risk Details
Description Unrealistic targets imposed by regulators with insufficient funding from commissioners to align the financial planto achieve targets
Impact - Inability to meet the expectations of regulators - Inability to achieve appropriate balance between delivery of responsive services and quality care with financialsustainability - inability to modernise the service and keep pace with the sector - Risk of regulatory intervention - Impact on reputation if the Trust is unable to achieve its targets
5Likelihood 4Severity Score 20
Initial Risk Rating
Actions
Target Date1No. 31/03/2018 Completed DateMark RedheadResponsible for Action / /
Action Description Include additional investment for DCA, AP roles and CAS within financial plan (phased). Spend and progressagainst delivery to be monitored through financial reporting and workforce plans; updates to be provided tocommissioners as to progress at monthly review meeting
Progress Budget position reported monthly through financial reports to FC, Board and NHSI. Workforce Planninginformation - including progress on recruitment plans, reported monthly to Workforce Planning group andbi-monthly to Workforce Committee. Task and finish group convened to oversee implementation of servicedevelopments to ensure effective and efficient use of resources to benefit service performance and patient safetybeyond implementation.
Date Entered : 07/08/2017 15:57Entered By : Mark Redhead
Outcome Details Awaiting Further Act
2 3 ScoreSeverityLikelihood 6
Target Risk Rating
06/09/2017
ReviewFrequency
Reviewed By ReviewDate
Review DetailsLastReviewDate
Mark Redhead Financial performance is monitored monthly and on track to deliverfinancial plan at outturn - based on M4 forecasts, Current responseperformance for R2 is below trajectory despite continuing spend on 3rdparty cover. Failure for this investment to improve R2 performance willincrease pressure for further expenditure to manage responseperformance which may put financial plans under pressure. Any action toreduce performance risk must therefore be managed within existingfinancial resources.
06/09/2017
Mark Redhead Whilst financial performance continues to be monitored monthly and is ontrack to deliver financial plan at outturn, current response performance forR2 is below plan trajectory despite continuing investment in 3rd partycover in Q1. Failure for this investment to improve R2 performance willincrease pressure for further expenditure to manage responseperformance which may put financial plans under pressure. Any action toreduce performance risk must therefore be managed within existingfinancial resources.
31/07/2017
Monthy
Reviews
Date Printed: 17/10/2017 Page 15 of 21ULY301 - Risk Register Report V2
RISK REGISTER
Mark Redhead Financial performance is being monitored against NHSI Plan submissionon a monthly basis internally (through FC, Board) and externally (throughNHSI returns). Current performance is ahead of Plan and in line with Planin terms of outturn. Ongoing monitoring and assessment of financialdelivery risk in the face of operational and service delivery pressures.
27/06/2017
Date Printed: 17/10/2017 Page 16 of 21ULY301 - Risk Register Report V2
RISK REGISTER
01. Corporate / Organisational
Caroline ThurlbeckKaren Forsyth Risk AssessorRisk Owner
Risk Reference Version Date IdentifiedORR-51 3 18/05/2017 Status Ongoing
Risk Details
Description Insufficient manpower resources and inability to recruit to vacancies prevent NEAS from delivering finance andperformance targets.
Impact - inability to meet regulatory and stakeholder expectations - inability to deliver a quality and safe service to patients - inability to deliver performance trajectories due to significant vacancies - inability to deliver new services such as the Clinical Assessment Services and Out of Hours services due to lackof multi-disciplinary professionals, resulting in potential loss of contracts - negative impact on quality and patient care due to lack of resources to respond - incurring significant third party costs due to inability to recruit
5Likelihood 4Severity Score 20
Initial Risk Rating
Controls in Place
Details of Control Recruitment programme for national and international paramedics in place
Pipeline may be impacted by BREXIT concernsGaps in Control
Effectiveness Satisfactory
Details of Control Workforce plan in place with pipeline for 17/18 and 18/19
Longer term forecasting still required.Gaps in Control
Effectiveness Adequate
44 ScoreSeverityLikelihood 16
Residual Risk Rating
Actions
Target Date1No. 31/03/2018 Completed DateNeil GatenbyResponsible for Action / /
Action Description Delivery of recruitment plan for clinical and associated support roles
Progress
Outcome Details Awaiting Further Act
3 3 ScoreSeverityLikelihood 9
Target Risk Rating
08/08/2017
ReviewFrequency
Reviewed By ReviewDate
Review DetailsLastReviewDate
Caroline Thurlbeck Recruitment plan for paramedics and other clinical roles. Some supportservices role impacted by restructure phase 2.
08/08/2017Monthy
Reviews
Date Printed: 17/10/2017 Page 17 of 21ULY301 - Risk Register Report V2
RISK REGISTER
01. Corporate / Organisational
Mathew BeattieGraham Tebbutt Risk AssessorRisk Owner
Risk Reference Version Date IdentifiedORR-52 11 19/05/2017 Status Ongoing
Risk Details
Description Loss of NHS111 service and associated Clinical Assessment Services (including 999 revalidation hub)
Impact - reputational damage - negative impact on 999 contract - financial sustainability impact due to co-dependency - impact on commissioners as 999 costs increase - NEAS becomes less attractive to potential employees - knock-on impact on ability to win new business - loss of skilled NEAS employees, who would be TUPEed to new provider - impact on financial sustainability - loss of seamless service impacts on the provision of sound clinical advice to patients
4Likelihood 4Severity Score 16
Initial Risk Rating
Controls in Place
Details of Control NHS 111 bid team in place, with a supporting meeting structure. The PID has been drafted and approved by ET.
PQQ / ITT not yet released so detailed specification is not yet knownGaps in Control
Effectiveness Some Weakness
Details of Control Good Governance; Project Board in place, SMEs identified and working group set up.
There is still some uncertainty about timings which may affect the availability of key staffGaps in Control
Effectiveness Some Weakness
Details of Control Bid support specification being developed for procurement
Business case/ budget not yet agreedGaps in Control
Effectiveness Uncertain
Details of Control Preparation for potential extension of contracts (from Apr 18)
Staff not yet aware of risks, risk of not partnering with Vocare (legal challenge) and recruitment to CASGaps in Control
Effectiveness Some Weakness
44 ScoreSeverityLikelihood 16
Residual Risk Rating
Actions
Target Date1No. 01/09/2017 Completed DateColette KnowlesResponsible for Action / /
Action Description Secure external bid support
Progress Procurement process ran and completed 03/10/2017. Decision with ET for approval.
Date Entered : 06/10/2017 09:42Entered By : Colette Knowles -----------
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RISK REGISTER
Colette and Ed tasked to undertake this
Date Entered : 24/07/2017 22:05Entered By : Graham Tebbutt -----------ED Hutton tasked to look at scope for potential support for Bid development
Date Entered : 05/06/2017 09:08Entered By : Christopher Black -----------Specification for external support is in development and will be shared with the Project Board
Date Entered : 19/05/2017 08:15Entered By : Jennifer Boyle
Outcome Details Outcome Under Review
Target Date2No. 29/09/2017 Completed DateGraham TebbuttResponsible for Action / /
Action Description SMEs to review content for bid and review previous content
Progress timescale has slipped as some areas still incomplete (ca.4 SME topics) Other topics have been reviewed andfeedback is due to be given.
Date Entered : 16/08/2017 07:39Entered By : Graham Tebbutt
Outcome Details Awaiting Further Act
Target Date6No. 21/09/2017 Completed DateKaren ForsythResponsible for Action / /
Action Description Provide TUPE lists to Commissioners and prepare for staffing implications of being successful or unsuccessful inthe bid
Progress
Outcome Details
3 4 ScoreSeverityLikelihood 12
Target Risk Rating
25/09/2017
ReviewFrequency
Reviewed By ReviewDate
Review DetailsLastReviewDate
Graham Tebbutt Business case approved. Revised project Plan to go to Transformationboard this week.
25/09/2017Monthy
Reviews
Date Printed: 17/10/2017 Page 19 of 21ULY301 - Risk Register Report V2
RISK REGISTER
01. Corporate / Organisational
Joanne BaxterDebra Stephen Risk AssessorRisk Owner
Risk Reference Version Date IdentifiedORR-53 4 02/06/2017 Status Ongoing
Risk Details
Description Potential risk to non delivery of CQC improvement plan within timescales agreed
Impact reputational damage and risk to Good rating
4Likelihood 4Severity Score 16
Initial Risk Rating
Controls in Place
Details of Control Robust action plan in place with timescales and reported to Quality Governance Group, Executive team andQuality Committee for monitoring
timescales are being extended from those initially agreedGaps in Control
Effectiveness Some Weakness
Details of Control Compliance Officer monitors progress against plan and escalates delays to appropriate managers
managers do not always respond and evidence not awlays providedGaps in Control
Effectiveness Some Weakness
43 ScoreSeverityLikelihood 12
Residual Risk Rating
Actions
Target Date3No. 29/09/2017 Completed DatePaul LiversidgeResponsible for Action / /
Action Description dates extended for 4 actions from improvement plan. timescales to be adhered to to prevent slippage
Progress works in the operations centre now complete. Have requested from the Operations Manager a date for when thelive test will take place.
Date Entered : 13/10/2017 08:02Entered By : Paul Liversidge -----------unfortunately the heating works have been delayed hindering our ability to carryout a live test. October is stillplanned but may slip. Director of Finance and Resources working with the Operations Centre Management teamto reach a mutually agreed financial and operational solution.
Date Entered : 06/10/2017 09:58Entered By : Paul Liversidge -----------Managers advised, any slippage to be raised with me.
Date Entered : 02/10/2017 16:38Entered By : Paul Liversidge -----------CQC compliance manager progressing actions with relevant responsible operational managers. Any concernsto be escalated, assessor advised.
Date Entered : 22/09/2017 07:38Entered By : Paul Liversidge
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RISK REGISTER
Outcome Details Outcome Under Review
3 2 ScoreSeverityLikelihood 6
Target Risk Rating
22/09/2017
ReviewFrequency
Reviewed By ReviewDate
Review DetailsLastReviewDate
Joanne Baxter Delivery of the 4 outstanding actions relating to EOC escalated to chiefoperating officer as timescales extended past agreed dates for close out
22/09/2017
Joanne Baxter all evidence submitted to demonstrate closure and compliance with theplan has been reviewed and signed off by all directors. plans in placewith new dates agreed for the four outstanding actions from the plan.COO to monitor overall delivery within service lines.
16/08/2017
Quarterly
Reviews
Date Printed: 17/10/2017 Page 21 of 21ULY301 - Risk Register Report V2
