board assurance framework - northerntrust.hscni.net · board assurance framework ... analysis of...

VERSION 6 – 8 APRIL 2013

Gov Com 2/13 Item 11.2

1

Board Assurance Framework

8th

April 2013



2

Objective 1: To Provide Safe and Effective Care

Objective 2: To create a culture of continuous improvement that supports the delivery of health and social care that exceeds recognised quality

standards and meets performance targets.

Objective 3: To use all of our resources wisely

Objective 4: To have a professional management culture with effective leadership, development of staff and teams that deliver

Objective 5: To involve and engage service users, carers, communities and other stakeholders to improve, shape and develop services



3

Corporate Objective 1 – To Provide Safe and Effective Care Principal Risk Reference 1.0

Ensuring safe practice and appropriate management of risk and balance of organizational priorities

• Patient Safety

• Patient Experience

• Finance

• Workforce Priority / Source Quality Standards for Health and Social Care -Standard criteria 5.3.1

Existing Controls Assurances Internal (I) External (E)

Reporting arrangements

Gaps in Controls / Assurance

Action Update in current quarter

Executive Lead

Timescales

•Integrated Governance Strategy •Risk Management strategy and Risk Management system. •Policies Standards and Guidelines Committee. •Audit and Effectiveness Programme •Action plans to address recommendations from RQIA reports •Action plans from Case Management reviews (CMRs) and Independent Agency reviews (IARs), National Confidential Enquiries •DHSSPS Risk Management Guidelines ‘Promoting Quality Care’ •Clinical coding •Mortality Data monitoring group

•Internal Audit reports (E) •RiskManagement2010 satisfactory •Reports of reviews by Regulatory Bodies inc RQIA/Royal Colleges/JAG (E) •Independent review reports/Case Management Reviews/Ombudsman Reports (E) •Reports to directorate governance forums re SAIs, incidents, complaints. (I) •CPA inspection and accreditation of Laboratories (E) •Controls Assurance standards Self Assessment scores (I) and Independent Verification (E) • Standard Mortality Ratio

RQIA reports,

HCAI reports,

SAI Review

Group

Governance

Management

Board

Directorate

Governance

Meetings

Complaints,

PSQIP

Risk Management Annual Report to Trust Board from 2010.

Classification of risk in line with other Trusts- Regional Risk matrix being finalised,

Currently being consulted on, NHSCT awaiting final confirmation of adoption of regional matrix Update from

Regional Group

Chair there has been

a delay in agreeing

descriptors. On this

basis timescale

extended from 31

March 2013 to 30

June 2013.

Medical Director 30 June 2013



4

•Register of licences and accreditation •Regular monitoring of workforce levels •Compliance with minimum nurse staffing levels •Finance report tabled at Trust Board Monthly •Nursing Dashboard •Patient Experience Standards •Nursing Assurance Framework

and Risk Adjusted Mortality index data (E) • Breast Screening Unit. QA report from NI QARC Nov 2011 • HCAI monitoring and report to Trust Board monthly • Assistant Director of Nursing monitoring of vacancies and agency spend • Monthly medical staffing updates to Medical and HR Directors • Patient experience surveys and observations of practice

Staff may find

it difficult

access to the

current

versions of

policies using

staff net

Matter referred to

BSO, issue remains

outstanding. On this

basis timescale

extended from 31

March 2013 to 30

June 2013

Head of Corporate Communications

30 June

2013

Introduction of Nurse

Sensitive KPIS

Dashboard under

Development for

monitoring and reporting,

refinement continues.

The trust continues to sample clinical areas in line with agree regional steer and reports through to PHA within

Nurse Sensitive KPIs have been piloted in C3 – spread plan to all wards commenced. 3 Nurse Sensitive

KPIs ie Falls walking

stick/Skin

Bundle/Record

keeping have been

Director of Nursing

30 June

2013



5

Nursing Assurance

Framework presented at

NET – biannual reporting

to PHA commencing April

2013Self

Assessment of trust

compliance

demonstrated high levels

of assurance with minor

amendments to achieve

100% compliance with all

professional standards.

pre-agreed timescales Fallsafe

Bundle and

Skin Bundle

included in

Commissioni

ng indicators

for

2013/2014,

work

underway to

achieve

same

introduced to 6 Adult

Acute Wards (30%),

spread plan

continues

Implementation Plan

for Directorate

reporting on

Professional

assurance indicators

in draft for approval.

On this basis

timescale has been

reviewed from 31

March 2013 to 30

June 2013

Implementation of Regional Caseload Weighting Tool for Child Care Social Work staff(E)

Social Work Issues Forum (I) Children’s Service Improvement Board (E) Professional Social Work Forum (I) Directorate Governance Forum(I)

Analysis of initial roll out to be completed by 28 February 2013. Initial analysis

complete. To be

considered by Social

Work Issues Forum

on this basis review

timescale changed

from 28 February

2013 to 30 June

2013

Executive Director Of Social Work

30 June 2013

Limited assurance in audit of locums

67% of Priority 1 findings complete and 63% of Priority 2 at

Medical Director 30 June 2013



6

September 2012. Project Board established to meet February 2013 The Trust is

participating in a

Regional Contract

Adjudication process

for locum agencies

due for completion

June 2013

Corporate Objective 1 – To Provide Safe and Effective Care

Principal risk Reference 1.1

Failure to achieve PfA target times of 4 hours and 12 hours for patients presenting to Emergency Departments

Priority / Source Quality Standards for Health and Social Care - Ensuring Safe Practice and appropriate management of risk- Standard Criterion 5.3.1 From Apr 12, 95% of patients attending any A&E department to be treated, discharged home or admitted within 4 hours From April 12 no patient should wait longer than12 hours in A&E department to be treated, discharged home or admitted

Risk Register - 25





Executive Lead

Timescales

•24/7 Patient Flow Staff •Escalation Plan •Daily Action Plans agreed at escalation meeting re patient throughput •Daily monitoring and

� PCC patient experience snapshot survey

� Hinds Report (E)

Reporting on Action Plan to Trust Board monthly •Performance

Mechanisms to

manage demand

in unscheduled

care

High Volumes of

Actions outlined in

Unscheduled Care

Action Plan

continued

Director of Acute Services

30 April 2013



7

escalation meeting of Trust staff regarding site positions. •Incident reporting. •HSCB monitoring and reporting of patients breaching 12 hour waits •Unscheduled Care Programme Board chaired by CE

� Rutter Report (E)

� Support Team (E)

Management Reports to Trust Board (monthly) •Unscheduled Care Action Plan is presented to Trust Board Monthly. •Performance reports to SMT (weekly) •Performance reports to HSCB (monthly) •Performance report to Trust Board (monthly) Performance report to HSCB (quarterly)

-

Patient arrivals

Patient

Complexity

High acuity

Patients waiting

in ED waiting for

decant to wards


Principal risk Reference1.2

Maintenance of community equipment is not provided consistently across the Trust

Priority / Source Quality Standards for Health and Social Care - Ensuring Safe Practice and appropriate management of risk- Standard Criterion 5.3.1

Risk Register - 20



8





Executive Lead

Timescales

� Database of stock provides facility to

assist with tracking of equipment � Clinical Engineering/ Aids and Adaptations � Maintenance contracts tendered through PALS � Estates Action Desk provides tracking for all

repairs requested � Triage system to establish the cause /

severity of faults reported by service users

• Equipment and asset register for community equipment and maintenance schedules have been completed

Joint Estates

and PPCOPS

action plan in

place and

reviewed

monthly

Risk is

recorded on

Corporate Risk

Register which

is reviewed by

the

Directorate

Governance

Committee

which reports

to GMB and

Governance

Committee

Joint meeting

with Estates

and PCOPPS

Business case

currently

outstanding to

ensure the

delivery of a

standardised

maintenance

programme

A Business case

being developed

which aims to

establish planned

maintenance on all

items of community

equipment. No

further update

available at 31 March

2013 review

extended to 30 June

2013.

Directors of Primary and Community Care and Director of Planning, Performance Management & Support Services Persons responsible Assistant Director PCOPPS & Assistant Director/Head of Estates

30 June

2013



9


Principal risk Reference 1.3

Risk of failure to meet Regional targets in respect of mandatory surveillance of CDI and MRSA bacteraemia

Priority / Source Quality Standards for Health and Social Care - Ensuring Safe Practice and appropriate management of risk- Standard Criterion 5.3.1 Clostridium Difficile / MRSA Targets 2012/13 MRSA: 12 per year C DIFF: 59 per year (please note that MRSA relates to all ages, CDiff target for 2012/13 relates to aged >2

Risk Register - 20





Executive Lead

Timescales

• Infection Prevention Control Corporate Delivery plan 2010-2013

• Infection Prevention and Control Directorate Delivery Plan

• Infection Prevention & Control & Environmental Hygiene Committee

• Infection prevention and control strategy

• Escalation policy for use of single rooms in hospitals

• Directorate accountability arrangements for HCAI

• IRAT admission and assessment tool

• RQIA Announced and Unannounced Hygiene Inspections (E)

• Performance monitoring of:

- infection rates (C

diff and MRSA

bacteraemia)

Audit of Compliance

with care bundles. (I) &

(E)

PHA surveillance reports

(E)

• Trust Board receive monthly HCAI performance report.

• Strategic IPC Forum (SMT) receive monthly dashboard for HCAI.

IPECH review current performance

Inadequate Isolation facilities

Limited Funding

for BICS training

for domestic

staff

Where Domestic

Services staff

also carry out

food service at

ward level, this

impacts on ward

input cleaning

Compliance with

Pseudomonas action

plan will be

monitored through

the use of the

augmented care

tools and associated

action plans

Business Case for

separating the food

service and cleaning

duties has been

completed for

consideration, to be

Medical Director/ Director of Nursing

30 June

2013



10

• Daily review of use of side rooms and review at patient flow meetings Mon - Fri

• Outbreak policy

• Electronic surveillance system

• Mandatory infection control training for all staff (3 yearly face to face-of DVD and competency tools during in between years)

• CDI Public Inquiry recommendations

• RCA Policy of CDI and Staph Aureus bacteraemias

IPCN HCAI related audits:

• hand hygiene

• cleanliness matters(I)

• High Impact Intervention

• Use of regional audit tools for Environmental Cleanliness and Clinical Practice

• Directorate/service

governance teams (I)

• Visit by PHA and Dr Patel June 2011 (E) � C diff public Enquiry

Report and Trust Action

Plan

• Audit of management of each case of CDI undertaken by IPCN

• IPCNs involved in new

build and refurbishment

work

• All cases of CDI and Staph Aureus undergo an RCA. The RCA is then reviewed by Med

Pseudomonas water recommend-ations monitored by Water Safety Group Audit of CDI Management Results Report issued to clinical and senior management teams and Governance Action plans/outcomes issued by DIPC PHA via laboratory/epidemiology package. IPC team report results to clinical teams and DIPC at RCA.

hours and

frequencies that

should be in

place.

resubmitted for

approval 2013/2014

Timescale updated

from 31 March 2013

to 30 June 2013



11

Director/DIPC, CEO and Dir of Nursing with clinical teams

• Ribotyping of all CDI isolates to identify transmission. Comparisons, trends identified by epidemiology package.

Trust Blood Culture Policy

Trust ANTT Policy

Trust MRSA Policy

Line champion’s quality

improvement

programme

Audit of Compliance

with care bundles. (I) &

(E)

Monthly

Dashboard/Pe

rformance

reports

Addresses all issues

arising from MRSA

review

Visit/Lectures to

Trust from Stephen

Rowley (Director of

ANTT UK)

Pilot of new

documentation

successfully

completed in

Causeway Hospital

Introduction of IV

packs and staff

training planned.

Trust Blood Culture

Policy reviewed

Director of Nursing

31 March 2013



12

Work continues and

on this basis review

extended from31

March 2013 to 30

June 2013

Business Case

approved for 2013-14

capital scheme in

Neonatal Unit, Antrim

Hospital to address

recommendations of

Review of

Pseudomonas

Outbreak

Executive Director of Social Work & Director of Planning, Performance Management

30 June 2013



13


Principal risk

Reference No

Risk of adverse incidents resulting in harm to children/young people because of an increase in demand for services

coupled with an emerging trend in complexity of cases

Priority / Source Quality Standards for Health and Social Care - Ensuring Sfe Practice and appropriate management of risk- Standard

Criterion 5.3.1

Risk Register - 20

Existing Controls Assurances

Internal (I)

External (E)

Reporting

arrangeme

nts

Gaps in Controls /

Assurance

Action Update in

current quarter

Executive Lead

Timescales

•Directorate sub group for

Risk and Governance

•Revised monitoring

templates (PMSID

developed to ensure

consistent monitoring)

Breach report template to

PMSI implemented –

(Director of Children’s

services July 2010)

Daily review of unallocated

cases within Gateway

Teams, Family Support

Monitoring of numbers of

unallocated cases (I)

Roll out of Regional

Caseload Weighting Tool

(E)

A Trust Children's

Improvement Board

established to oversee

progress and weekly

analysis of breeches is

forwarded to Director with

actions reviewed and

updated against targets (I)

Monthly

Performan

ce report

Directorate

reporting

system

Corporate

Parenting

Report to

Trust Board

and

DHSSPS

(bi-annual)

100 % of Child

Protection

referrals to be

allocated to a

social worker

within 24 hours

of receipt of

referral

116 Unallocated

cases at 15/02/13

Commissioner has

made funding

available to recruit

additional social

workers and Band 4s

and have set targets to

reduce unallocated

cases.

Director of care

Family and child

services

30 April

2013



14

Intervention Teams,

Children’s Disability Teams

and measures to ensure

effective communication

with wider network of

professionals involved with

families

Ongoing prioritisation of

cases within teams

Priority guidance for staff



15


Principal risk

Reference No

Delays in treating patients and additional pressure on waiting lists due to inadequate emergency theatre provision in Antrim

and Causeway Hospitals.

Benchmarking exercise to compare NHSCT access to NCEPOD theatres with other Trusts. NHSCT has less availability.

Priority / Source Quality Standards for Health and Social Care - Ensuring Safe Practice and appropriate management of risk- Standard

Criterion 5.3.1

Risk Register - 20


Internal (I)

External (E)

Reporting

arrangeme

nts

Gaps in Controls /

Assurance

Action Update in

current quarter

Executive Lead

Timescales

• Daily monitoring and

prioritization on basis of

clinical need (risk assessed)

by General Manager –

Surgery

• Action plan includes-

emergency response

arrangement, prioritization for

surgery, contingency

arrangements,

postponed/cancelled elective

activity

• Surgeon of the week

• Reporting arrangements

to Director of Acute

services and escalation

where appropriate

• Performance reporting to

SMT

Reporting

to Director

of Acute

Services

Access to

Emergency

theatres in Antrim

and Causeway do

not meet

NCEPOD

recommendations

Director of Acute

Services

30 April

2013



16

(Causeway) and Day (Antrim)

to make clinical decisions

• Ongoing review of the

situation

Business case for additional

theatre capacity sent to HSCB

for consideration (Director of

Acute Hospital services).

Theatre sessions have been

re-profiled to generate vacant

theatre space.



17


Principal risk Risk of adult teams being unfamiliar with paediatric procedure and protocol for managing specific conditions, which could

potentially adversely affect clinical outcomes for adolescents in adult wards


Criterion 5.3.1

Risk Register - 16


Internal (I)

External (E)

Reporting

arrangements

Gaps in

Controls /

Assurance

Action Update in

current quarter

Executive Lead

Timescales

Policy, Standards & Guidelines Committee – IV Fluids for Children and Young People Policy, March 2010 Learning letter from Medical Director and Director of Nursing Reduce number of wards that admit under 18. Training programme in place for wards

RQIA Follow-up Review of Hyponatraemia, July 2010 (E) RQIA Review of Under 18 in Adult Wards, October

Progress against action plan. Report provided to GMB and Governance Committee Progress against action plan is monitored and

Requires an assurance audit for compliance with changes No competency assessment tool in place Requires an assurance

Audit of compliance by RQIA complete Regionally an RQIA Hyponatraemia Guideline Implementation Sub-Group, led by PHA, was established. They are currently working on developing a regional competency assessment tool Meeting to review under 18 action plan

Medical Director Medical Director

Complete 30 April 2013



18

that admit children/adolescents

2011 (E); RQIA under 18 report completed December 2012

reported to GMB and Governance Committee

audit for compliance with changes

scheduled for 21 March 2013 Action plan to be

presented to GMB

May 2013 for

approval, review

timescale moved to

30 May 2013

30 May 2013



19


Principal risk

Reference No

On-going medical staff vacancies across the Trust. These vacancies can impact upon the quality of care given to patients,

the training given to junior medical staff and financial balance (due to the high costs associated with locum medical staff).


Criterion 5.3.1

Risk Register 20


Internal (I)

External (E)

Reporting

arrangeme

nts

Gaps in Controls /

Assurance

Action Update in

current quarter

Executive Lead

Timescales

•Advertisement and

Recruitment of vacant posts

•Planned use of locum staff

•Contingency plans with core

staff

•Rotas developed (I)

Clinical Leads in place (I)

Reporting

and

monitoring

through

directorate

and MAA

systems

Advertisement of

Consultant posts in

wide range of

journals

Medical Director

Clinical Directors

Director of Acute

Services

30 April

2013



20


Principal risk Statutory Functions

Potential Risk of failing to meet the assessed needs of those who fall under delegated statutory functions


Criterion 5.3.1


Internal (I)

External (E)

Reporting

arrangeme

nts

Gaps in Controls /

Assurance

Action Update in

current quarter

Executive Lead

Timescales

•Social Care Registration

•Professional social work

forum

•Trust Social Work

Supervision Policy

•Directorate Governance

Framework

•Delegated Statutory

Functions Monitoring and

reporting (I)

•Delegated Statutory

Functions Feedback

Report by HSCB &

DHSSPS (E)

•Annual Safeguarding

Reports for Children and

Adults (I)

•RQIA Inspection

Programme (E)

•Delegated

Statutory

Functions

Report to

Trust

Board

(Annual)

Action Plan to

address and review

DSF Feedback from

HSCB and DHSSPS

subject to ongoing

monitoring

Executive Director

of Social Work

30 April

2013



21


Principal risk Use of unregulated placements for 16-18 year olds outside the care system.


Criterion 5.3.1


Internal (I)

External (E)

Reporting

arrangeme

nts

Gaps in Controls /

Assurance

Action Update in

current quarter

Executive Lead

Timescales

• Joint commissioning

arrangements

•Monitoring of use of

unregulated placements

•One Social Worker for work

with homeless young people

• Monthly report to HSCB of

16+ placements.

•RQIA have inspected

premises.

Standards for placement of

16+ years.

Stat

functions

report.

Corporate

parenting

reports.

Foster Carer

recruitment for 16+

ongoing and this has

contributed to

reduction of

unregulated

placements.

Executive Director

of Social Work

30 April

2013



22


Principal risk

Reference No

Limitations in Trust’s arrangements for commissioning and managing services being purchased from third party providers on

behalf of Trust.

(1)The ability to secure and sustain sufficient quality of social care provision

(2) The procurement of healthcare from third party providers is guided by the Regional Quality Framework


Criterion 5.3.1

Risk Register 16


Internal (I)

External (E)

Reporting

arrangeme

nts

Gaps in Controls /

Assurance

Action Update in

current quarter

Executive Lead

Timescales

SOCIAL CARE

RQIA Regulation of service

providers

•Contracting and monitoring

process

•Permanent Review team

•Care management process

•Vulnerable adult procedure

and process

•Complaints and incident

reporting (I and E)

•RQIA reviews (E)

•Quarterly Report to Trust

board on contracts

renewed or put in place (I)

•Feedback from staff,

service users and other

stakeholders (I and E)

Reference panels have

been established for

Recruitment of

band 6 Officer to

ensure effective

monitoring

process in place

and produce

quarterly report -

In process

Director of

Planning and

Performance

Monthly

30 June

2013



23

Policy for contract review May

12

HEALTH CARE

The region provides a select

list of acute IS providers

and undertake the

procurement process for

same, establish standards,

contracts and prices

Independent Home owners

and Domiciliary care

Providers.

Trust professional staff

working intensively with

poorly performing homes to

raise standards of care.

Learning from such

incidents has been shared

with Independent Providers

in feedback/workshop

sessions.

HEALTH

CARE

Complaint

s &

Incidents

reported to

Governanc

e

Departmen

t

Director of

Planning and

Performance

/Director of

Acute Services



24


Principal risk Potential risk of Noncompliance with Estates related statutory standards in Trust facilities and potential risk to service users,

staff and public.

Risk Register 12 Risk Register 15

Priority / Source Quality Standards for Health and Social Care – Corporate Leadership and Accountability of Organisations – Criteria 4.3 (g)


Internal (I)

External (E)

Reporting

arrangeme

nts

Gaps in Controls /

Assurance

Action Update in

current quarter

Executive Lead

Timescales

•Risk assessment and Risk

Management process

•HT Ms PELs issued by Health

Estates

•Collaborative working

between Trust and RQIA and

estates officer attending RQIA

inspections

•Process for prioritisation of

clinical equipment

replacement

•System for prioritizing bids for

general capital schemes and

minor works

• CAS compliance with

•Fire Safety

•Buildings, Land, Plant and

Equipment

Legionellia Survey and Risk

Assessment

Asbestos Survey and Risk

Assessment

Water Safety Plan

Action plan being

implemented

500k of capital work

Annual Fire

Safety

Report

Water

Safety

update

provided to

IPECH

Limited assurance

on Internal audit

of fire safety

Director of

Planning and

Performance

30 April

2013



25

underway across range of

facilities. Additional training

being provided.



26


Principal risk Preventing detecting, communicating and learning from adverse incidents and near misses.

Priority / Source Quality Standards for Health and Social Care - Preventing detecting, communicating and learning from adverse incidents

and near misses -Standard Criterion 5.3.2


Internal (I)

External (E)

Reporting

arrangements

Gaps in

Controls /

Assurance

Action Update in

current quarter

Executive Lead

Timescales

•Policies & Procedures for

identifying, reporting

monitoring and analysing

adverse

incidents/complaints/claims

•Reporting of complaints,

Incidents, risks. Reports

provided to HSCB, RQIA and

DHSSPSNI

•Training on Use of Root

Cause analysis type of

investigations into identified

Incidents

•Integrated Governance

strategy and associated

committees and sub

•Incident Reports(I)

•Reports of trends and

analysis of complaints,

compliments, incidents and

claims to Governance

Management Board and

Governance

•Committee (I)

•Serious Adverse Incident

reviews shared with

RQIA(I) MH&LD, PCOPPS

, Childrens and Acute

governance team meetings

MHD & LD SAI Review

Group

Governance

reports to

Governance

Management

Board (bi-

monthly) and

Governance

Committee

(quarterly).

Learning

alerts noted at

Governance

Assurance

required on

timely

implementation

of change

following

incidents and

other sources

of learning.

SAI Group continue to

meet and review

learning

Medical Director 30 April

2013



27

committees

•Trust-wide learning model

implemented

•SAI Review Group

established

•Nursing Executive

•Internal audit reported,

complaints and incidents

(limited assurance)

•Trust SAI Review Group

Shared Learning Model

Committee (I).



28


Principal risk Non – compliance with a number of statutory health and safety requirements

Risk Register 12

Priority / Source


Internal (I)

External (E)

Reporting

arrangements

Gaps in

Controls /

Assurance

Action Update in

current quarter

Executive Lead Timescales

Trust, directorate and

departmental policies and

procedures.

Provision of training.

Completion of risk

assessments.

Availability of Corporate H&S

Professional Staff including

IPCNs, fire safety, laser

protection advisors and

radiation protection advisors

Completion of incident

investigations.

Issue of learning alerts.

Trust H&S & related

Self-assessments against

H&S & other Controls

Assurance Standards

having a H&S content. (E)

RIDDOR reporting (E)

Incident Report Forms (I)

Quarterly reporting of

incident analyses and of

trends monitoring (I)

Bi-annual reporting by Trust

H&S & related Committees

(I)

Investigation of incidents

and dissemination of

learning across Trust (I)

Incident

analysis and

trend

monitoring

GMB and

Governance

Committee

H&S & related

specialist

Committee

reporting to

GMB & to

Governance

Committee (bi-

annually).

Controls

Assurance

Standards

Limited training

capacity &

reduced

attendance at

training.

Gaps in

compliance

with H&S

related policies

and procedures

Trust policies

required for

First Aid and

DSE

Provision of

replacement training

centre (April 2013)

Monitoring &

Reporting on

attendance at training

courses (ongoing)

Provision of training in

completion of risk

assessment (ongoing

Medical Director 30 June

2013



29

specialist Committees.

Provision of H&S related

information and campaigns

H&S Reports for TB compliance

levels to

Department,

GMB &

Governance

Committee

(annually)



30

Corporate Objective 1– To Provide Safe and Effective Care

Principal risk Non-compliance with legislation for Management of Controlled Drugs.

Priority / Source Quality Standards for Health and Social Care - Ensuring Safe Practice & appropriate management of risk - Standard

Criterion 5.3.1

Risk Register - 16


Internal (I)

External (E)

Reporting

arrangements

Gaps in

Controls /

Assurance

Action Update in

current quarter

Executive Lead

Timescales

Policies and Procedures for

management of controlled

drugs

•Medicine Inspectorate

(DHSSPS) annual

inspection (E)

•Controls Assurance

standards Self-Assessment

scores (I) and Independent

Verification (E)

RQIA Audit has been

completed(E)

Directorate

Management

Group

GMB

Governance

Committee

Capacity to

meet

requirements of

Controlled Drug

Regulations.

RQIA audit report

awaited, review is

complete

Medical Director 30 June

2013



31

Corporate Objective 2 – To create a culture of continuous improvement that supports the delivery of health and social care that exceeds recognised quality

standards and meets performance targets.

Principal risk Promoting Effective Care

Priority / Source Quality Standards for Health and Social Care -Standard Criterion 5.3.3


Internal (I)

External (E)

Reporting

arrangements

Gaps in

Controls /

Assurance

Action Update in

current quarter

Executive Lead

Timescales

� Person-centered care

planning

� Policy, standards and

guidelines committee

� Research Governance

Framework

� Patient and Public

Involvement strategy

• Carers strategy

• Policy Standards &

Guidelines Committee

• Patient Safety QIP

• Member of HSC

Collaboratives

� Clinical and Multi

professional audit reports

(I)

• User Feedback and

Involvement Committee (I)

• Patient Safety reports (I)

� Report of

Clinical and

Multi-

professional

Audits to

Governance

Committee

(Annual)

• Research

Governance

report to

Governance

committee

(quarterly)

• Patient

Safety

Performance

report to Trust

Senior

Management

Team

30 April

2013



32

• Partnership working with

Safety Forum

• Multi Professional Audit

Strategy

• Bereavement Strategy

Board

• Specialist

Advisory

Committee

Reports to

GMB

Link between

Clinical Audit

and Board

Assurance

to be

strengthened

Audit and

Effectiveness will

review at April

meeting


2013

Stocktake of

current

implementati

on status of

NICE

guidelines

issued pre

Oct 2011

complete

Waiting on finalised

report on NICE

guidance issued pre

October 2011


2013



33

Corporate Objective 3 – To use all of our resources wisely

Principal risk Failure to achieve statutory break even position

Priority / Source Quality Standards for Health and Social Care – Corporate Leadership and Accountability of organisations

Standard Criterion 4.3 (f)

Risk Register - 25


Internal (I)

External (E)

Reporting

arrangements

Gaps in

Controls /

Assurance

Action Update in

current quarter

Executive Lead

Timescales

Financial Accountability

arrangements

Process for monitoring budget

and formulation of corrective

action plans

Robust monitoring and

forecasting

Income agreed with

commissioners and monthly

meetings with HSCB Finance

Colleagues to discuss cost

pressures

Financial strategy and

annual financial plan

approved by Trust Board

(via TDP), HSCB and

DHSSPS

Modernisation and

Recovery Plan-Programme

and Project management

arrangements

Director accountability

arrangements

Monthly Director

accountability meetings

Financial

Performance

Report to

Trust Board

Monthly

Final

accounts to

Trust Board

and Audit

Committee

annually

Directorate

Financial

Position

Trust Delivery

Plan 2012/13

in draft format

Continued and

focused monitoring

of financial position

in 12/13 and

forecasting for 13/14

Director of

Finance

30 April

2013



34

Process for budget setting

Training for budget holders

(2012 additional training

provided 155/700 budget

holders)

Policy and procedure in place

for budget setting

Process for identification of

emerging pressures

Financial controls in place with

respect to discretionary spend

with DOF and CE Reports

Financial

Stability

review and

report on a

quarterly

basis



35


Principal risk To ensure systems are in place to ensure that financial management achieves economy, effectiveness, efficiency, probity

and accountability in the use of resources, to include prevention of fraud, achievement of CRL and assurance that expected

activity, productivity and outcomes are delivered


Standard Criterion 4.3 (f)


Internal (I)

External (E)

Reporting

arrangements

Gaps in

Controls /

Assurance

Action Update in

current quarter

Executive Lead

Timescales

Financial management

systems, policies and

procedures include:

• Standing orders

• Standing financial

instructions

• Authorisation

framework for

expenditure

• Budgetary framework

• Fraud and Corruption

plan

• Code of Conduct for

Internal Audit Reports (I)

Controls Assurance (I)

Assessment with respect to

Financial management

Purchasing and supply

Directorate & Finance spot

checks on absence returns

and information recorded

on HRMS (I)

HR spot checks on

compliance with Managing

Attendance Policy

compliance

Directorate Managing

Internal Audit

Reports and

Financial losses

report to audit

committee

CAS report to

audit committee

and Trust Board

annually

Annual DHSSPS

Procurement

report by COPE

Trust

Procurement

Board with PALS

Limited

assurance

on the

engagemen

t of agency

staff

internal

audit

Limited

assurance

in

attendance

manageme

nt internal

Review of usage of

non contracted agency

Best Practice Cash

and Valuables

Management

guidance issued

Finance returning

incomplete monthly

absence returns to

appropriate

Senior

Management

Team

30 April

2013



36

managers

• Gifts and Hospitality

policy

• Attendance

Management policy

• Standing Financial

Instructions

• NHSCT Ant-Fraud

policy

• Fraud awareness

training at Corporate

Induction

• Whistleblowing policy

• Performance

indicators with respect

to SBA, PfA, regional

targets and Trust

indicators

attendance management

action plans developed

and reviewed(I)

Director accountability

reviews

Trust Performance Report

(monthly)

Annual TFR and speciality

cost statements

Development of the

availability of CHKS data

will facilitate benchmarking

with peers

representatives

Whistleblowing

policy register to

GMB and Audit

Committee

audit

manager/director/HR

BP

Managers Aide

Memoire produced

Training and

guidance – ongoing

with Children’s

Directorate re

financial controls

Enhanced financial

controls scrutiny

underway in outlying

facilities

Fraud awareness

training to be

available on regular

basis



37


Principal risk Quality Improvement activity is not captured to provide corporate assurance

Priority / Source Quality Standards for Health and Social Care – Safe and Effective Care

Standard Criterion 5.3.3 (i)


Internal (I)

External (E)

Reporting

arrangements

Gaps in

Controls /

Assurance

Action Update in

current quarter

Executive Lead

Timescales

Audit & Effectiveness Plan Patient Safety Quality Improvement Plan (PSQIP)

Audit & Effectiveness reports (I) Patient Safety Performance Report (I)

Audit & Effectiveness annual plan monitored by Audit & Effectiveness Committee and annual report presented to GMB and Governance Committee Patient Safety activity monitored by Patient Safety Steering Committee and regular reports provided to GMB, Governance Committee and

Ensure that audit plans for each Directorate are incorporated into their service plans Ensuring that the four operational Directorates participate in the PSQIP

The next Audit & Effectiveness Committee meeting has been scheduled for April 2013 and will review the Trust audit plans Patient safety, quality improvement initiatives being considered / modified for use in Children’s & PCCOPS

Medical Director Medical Director

30 April 2013 30 April 2013



38

Trust Quality Strategy (approved at Trust Board, September 2012)

Trust Board Quality priorities need to be incorporated into directorates’ 2013/14 service plans

Quality Strategy self-assessment tool being piloted during March 2013 within 2 Directorates. Plan to roll out from April 2013. The Trust will be required to produce a Quality Annual Report by April/May 2014. Trust represented on Regional Group devising format for Annual Quality Report.

Medical Director

30 April 2013 April/May 2014



39


Principal risk Service planning process

Priority / Source Quality Standards for Health and Social Care – Accessible, Flexible and Responsive Services

Standard Criterion 6.3.1 Service Planning Processes (a-f)


Internal (I)

External (E)

Reporting

arrangements

Gaps in

Controls /

Assurance

Action Update in

current quarter

Executive Lead

Timescales

Service planning guidance

policy and procedure

adopted by the Trust

Performance Monitoring

Arrangements:

-monthly chaired by Chief

Executive

-monthly integrated directorate

performance meeting chaired

by director

PPI Strategy

Shared learning process

implemented.

Performance Management

Framework &

Performance reporting (I)

•HSCB performance

monitoring (E)

Performance reporting to

directorates, SMT and

Trust Board (I)

•User feedback and

Involvement committee (I)

•Public representation in

Mental Health service

•Disability panel

•PPI Annual report

•Performance

Report to

Trust Board

(monthly)

•Performance

report to SMT

(weekly) and

HSCB

(monthly)

•Performance

reports to

IPC&EH

Committee

(monthly)

•IPC&EH

committee

monitoring of

delivery plans

An established

mechanism for

engagement

with

stakeholders on

corporate

issues.

Policies continue to

be developed to

expand the areas

covered by robust

practices eg

Domiciliary care

Escalation Policy,

Senior

Management

Team

30 April

2013



40

Transforming Your Care

planning group

HSCB/PHA Commissioning

plan

Management Letter signed

2010/11

Corporate plan 2011 2014

Directorate plans 2011 -2012

Complaints and User

Feedback Policy

Standardised template with

guidance for service plans, to

include PPI and quality

initiatives.

•Patient Experience

Survey(I)

Satisfactory Internal audit

report

quarterl

•Minutes of

User

Experience

and

Involvement

committee to

Governance

Committee

(Quarterly)

•PPI Annual

Report

•Mid year

review of

corporate

plan with TB



41


Principal risk Potential risk of failing to involve stakeholders in the service planning process

Priority / Source Quality Standards for Health and Social Care – Accessible, Flexible and Responsive Services

Standard Criterion 6.3.2 Service Delivery for Individuals and Relatives


Internal (I)

External (E)

Reporting

arrangements

Gaps in

Controls /

Assurance

Action Update in

current quarter

Executive Lead

Timescales

DHSSPS Patient Experience

Standards

Trust Mission and Values

Patient Experience Survey

Process

Complaints and User

Feedback Policy

Policies and procedures for

assessment, planning and

provision of care

SAI /Incident investigation

process

Shared Learning Model

Leadership walkrounds

RQIA Reviews.

C Diff Enquiry report (E)

2011

PCC snapshot survey A&E

2011

Professional Regulatory

Bodies reports (I & E)


Reports ( Quarterly)

Users views and

complaints

Patient experience admin

officer in post from October

2012

Reports to

Service user

&

Engagement

committee

and

Governance

Committee

(Quarterly).

Assurance

required

regarding

communication

with patients in

hospital.

Assurance

required on

patient

experience.

Senior

Management

Team

30 April

2013



42

Speaking to patients

Carers Strategy

Professional Regulatory

Bodies reports (I & E)


Reports ( Quarterly)

Users views and complaints



43


Principal risk Risk: Potential Risk

If reform and modernisation is not realized, targets and financial efficiencies may not be achieved

Priority / Source Quality Standards for Health and Social Care – Corporate Leadership and Accountability of Organisations 4.3 (F)


Internal (I)

External (E)

Reporting

arrangements

Gaps in

Controls /

Assurance

Action Update in

current quarter

Executive Lead

Timescales

•Corporate Plan which sets

out strategic vision

Performance Management

Framework which sets out

accountability arrangements

and includes:

•SBA volumes agreed with

Commissioner

•Directorate senior team

meetings and vacancy

controls

•Engagement with HSCB on

ongoing basis

•Acute Hospitals

Reconfiguration Project

management structure

•Modernisation and Recovery

•Performance Reports –

weekly to SMT and monthly

to Trust Board (I)

•Directors Accountability

Meetings with CEO (I)

•Performance &

Accountability meetings

with HSCB (E)

•Transforming your care

Programme Board and

accountability

arrangements Forum.(I)

•Bi-annual meeting with

DHSSPS (E)

•Weekly elective access

meeting (I)

•Performance

Reports to

Trust Board

(monthly)

•Performance

reports to

SMT (weekly)

CSR TYC

Programme

Board

Reports to

HSCB

No material

gaps.

Regional consultation

complete. The Trust

will take forward local

consultations, where

required, and as

guided.

Director of

Planning and

Performance

Monthly

reports



44

Plan

• Unscheduled/Scheduled

Demand/Capacity Escalation

Plan & Escalation strategy

•Risk Registers

•Corporate plan

Elective Access Protocols



45

Corporate Objective 4 – To have a professional management culture with effective leadership, development of staff and teams that deliver

Principal risk Recruitment of staff


Standard Criterion 4.3 Criteria J-N Workforce Planning Induction, training, pre-employment checks, appraisal and

supervision


Internal (I)

External (E)

Reporting

arrangements

Gaps in

Controls /

Assurance

Action Update in

current quarter

Executive Lead

Timescales

• HR Strategy and Action plan

• OD strategy & Action plan.

• Recruitment and Retention

strategy and action plan

• HR Policies and Procedures

• HR Framework for managers

and employee relationships

• Trust Policy approval

process

• Whistle-blowing policy

•Health & Wellbeing at work

strategy

HR section of Performance

report. Annual HR activity

report (I).

Staff Care call & U-Talk

analysis (I).

CAS Governance -85%

(Internal Audit) (2011-

2012).

CAS HR

Analysis of

absence/disciplinary

information (I)

Performance

report to SMT

and Trust

Board

(monthly).

Annual HR

Activity report

to Trust Board

(annually).

Internal Audit

reports to

Audit

committee

Effectivenesss

of

organisational

arrangements.

Quality

assurance of

medical

appraisal

process.

Oncore training

management

system will be

replaced by

HRPTS which

will provide an

integrated

Senior

Management

Team

Quarterly

Review



46

•Occupational Health Service

• Staff Induction for Trust Staff

and NIMTDA Doctors in

training

E Learning Induction for

Locum Doctors

Training tracker for long-

term locums and other

medical staff

• NHSCT Policy for medical

practitioners appraisal and

revalidation

• NIMTDA standards for

doctors in training

• NIMTDA Policy for appraisal

of doctors in training

• Leadership training for

managers

•Staff Mentorship

•Nursing Supervision-

monitoring and recording

systems updated to enable

reporting per directorate

RQIA report of Consultant

appraisal (E) 2010

Deanery Visits (E)

NIMDTA interviews with

doctors in training (E)

Staff survey report and

action plan-

•regional staff survey

results and action plan

•internal e-mail staff

survey results

•internal nursing staff

survey results

•internal support staff

survey results

CAS

Health & Safety

Management 73% (2011-

2012)

(Quarterly).

Annual report

of Consultant

Appraisal to

Trust Board

(annually).

Whistle

Blowing

register is

monitored

monthly

training and HR

record for all

Trust staff

System for

recording all

staff training

identified as

assurance gap

Reduced levels

of training

doctors across

a number of

specialties

especially



47

•Midwifery Supervision

Junior Doctor monitoring

for EWTD and New Deal

emergency

medicine 2011



48

Corporate Objective 4 – To have a professional management culture with effective leadership, development of staff and teams that deliver

Principal risk Potential risk of impact on staff morale and stress from financial position, Contingency measures and workload


Standard Criterion 4.3 Criteria N - Workforce Strategy


Internal (I)

External (E)

Reporting

arrangements

Gaps in

Controls /

Assurance

Action Update in

current quarter

Executive Lead

Timescales

Management of Change HR

Framework

•Trade union and

management meetings

•JNCF bimonthly meetings

•Trade Union committee

monthly meetings

•CSR group

•CSR Programme board and

project teams

•Health & Wellbeing and

Health & Safety group

•U–talk

Sickness and absence

reports (I)

•Staff survey ( I) 2012

•Referrals to Occupational

Health (I)

•Care Call (I)

Sickness and

absence

reports to

Trust Board

(monthly).

Directorates currently

considering

Directorate

Engagement Plans.

Further staff survey

complete.

Survey analysis issued

to directors for

discussion at SMT.

Directorate specific

engagement plans to

be reviewed and

updated as necessary.

Senior

Management

Team

Monthly



49

Team Brief

Staff Engagement Strategy

and engagement plan

Health and Well-being action

plan developed and underway.

Directorate Managing

Attendance Action plans

which will include analysis of

reasons for absence to identify

trends/issues which require

other interventions



50

Corporate Objective 5 - To involve and engage service users, carers, communities and other stakeholders to improve, shape and develop services

Principal risk Effective Communication and Information

Priority / Source Quality Standards for Health and Social Care –

Corporate Leadership and Accountability of organisations - Standard Criterion 4.3 (d)

Promoting, Protecting and Improving Health and Social Wellbeing - Standard Criterion 7.3 (b & e)

Effective Communication and Information -- Standard Criterion 8.3 (a&b)


Internal (I)

External (E)

Reporting

arrangements

Gaps in

Controls /

Assurance

Action Update in

current quarter

Executive Lead

Timescales

•Personal & Public

Involvement Strategy & Action

Plan 2009-12 (2013-2015

currently being consulted on)

•Communications Strategy

•Integrated Governance

Strategy

� Equality Scheme

� Health and Wellbeing at

work strategy

•Community Development

•User Feedback and

Involvement Committee

reporting arrangements (I)

•Media activity reported to

SMT and Trust Board. (I)

•RQIA Review Reports (E)

•Patient Client Council

Representative on User

Feedback Committee

•Local politicians (E)

•Section 75 Annual

progress report to the

•User Feedback

and

Involvement

Committee

reporting

arrangements

(I)

•Media activity

reported to SMT

and Trust

Board. (I)

•Patient Client

Council

Representative

Community

Development

Strategy and

PPI Strategy

to be linked

PPI Strategy 2013 –

2015 – approved

Consultation

Joint PPI/Community

Development

Implementation

Framework is currently

being considered

Senior

Management

Team

Quarterly



51

strategy

•Reform and Modernisation

Plan

� Disability Action Plan

Equality Commission (I) &

(E)

• PPI Annual Report

• Regular audit of

information given to

patients and families re c

diff

� Trust Equality Committee

� Annual Progress Report to

ECNI

on User

Feedback

Committee

•MLA Enquiries

•Section 75

Annual

progress report

to the Equality

Commission (I)

& (E)

•PPI Annual

Report

•Regular audit

of information

given to

patients and

families re c diff

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