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present the detailed single page format of the Board Assurance Framework at Appendix 1;

A summary of the risks held on the Corporate Risk Register;

A position report on the current Risk Management Improvement Plan.

The Board Assurance Framework has been developed in consideration of the strategic objectives and sub aims outlined in the Trust’s 2018/19 Operational Plan that was approved by the Board in May 2018. The Trust’s Operation Plan 2018/19 identified four strategic objectives; Quality, People, Partnerships and Resources and fourteen sub aims associated with these objectives.

The principal risks to delivery of each of the sub aim have been identified and are provided in Appendix 1. Further review of the principal risks has taken place and proposed revisions are contained in this report. Members are asked to approve the proposed revisions.

There are 29 open risks on the Corporate Risk Register and these have been cross-referenced against the Trust’s Strategic Objectives, CQC domains and to the relevant Board Committees. A dashboard view of the Corporate Risk Register is provided in Appendix 2.

Following risk review:

1 existing risk has increased in score (4301);

1 divisional risk has been escalated onto the Corporate Risk register (6443);

1 risk has been closed (6655);

3 risks have reduced in score and been de-escalated from the Corporate Risk Register (Highlighted in grey Appendix 3 and Table 2 – IDs 6827, 6857, 6855).

A summary update on the progress of the Risk Management Improvement Plan is provided in this report and details the next steps to further enhance the revised approach to risk management in the Trust.

3

Risk and Assurance Management Report

1 Introduction / Background

1.1 This report aims to provide members with details of the newly approved principal risks held on the revised Board Assurance Framework (BAF). It also provides a summary of all risks held on the Corporate Risk register (CRR) which comprises risks scoring 15 and above or risks that have a trust wide impact.

1.2 The body of this report contains a detailed view of changes to the CRR, including newly identified, closed, escalated and de-escalated risks. It further provides a breakdown of the number of risks by Director, Strategic Objective, CQC domain and Assuring committee and will note overdue mitigating actions. Corporate Risk Register Risks are reviewed monthly to facilitate the refresh and updates to the register.

1.3 The Corporate Risk Register and Principal risks are provided to the Shaping Our Futures (SOF) Provider Board on a quarterly basis. Risks held by the Trust which impact on the system are included in the System Wide Risk Register along with those held by partner organisations.

1.4 An update is also provided on the progress of the Risk Management Improvement Plan, aimed at strengthening risk management at all levels of the organisation.

Key terms used in this report:

Board Assurance Framework (BAF): Key document which records the principal risks to strategic objectives. The BAF also provides the Board with sources of assurance that controls are working effectively.

Corporate Risk Register (CRR): A register of all operational risks with scores of 15 or more or those deemed to have an organisational wide impact.

Current risk Score: Assessment of risk score using 5x5 risk matrix, taking into account current mitigation

Divisional Risk Register: All risks scoring 1-12.

Principal risk: A risk which threatens achievement of the Trust’s strategic objectives.

Risk scores:

1-3=’Low risk’

4-6=’Moderate risk’

8-12=’High risk’

15-25=’Extreme risk’

Target risk score: The estimated achievable risk score when all actions are completed.

4

2 Principal risks – Board Assurance Framework (BAF)

2.1 The 2018/19 Board Assurance Framework and the principal risks have been developed in consideration of the strategic objectives and sub aims outlined in the Trust’s 2018/19 Operational Plan that was approved by the Board in May 2018.

2.2 The Trust’s Operation Plan 2018/19 identified four strategic objectives; Quality, People, Partnerships and Resources and fourteen sub aims associated with these objectives. The principal risks to delivery of each of the sub aim have been identified and scored, and presented to Board on the 4th October 2018 for approval.

2.3 The current Board Assurance Framework, including detail and rationale for scoring is provided in Appendix 1 Board Assurance Framework Single Page Format Report.

2.4 The Board approved the risks but requested that the Executive Team review the scoring of all the principal risks identified. This review as taken place with Executive Leads and the resultant proposed scores amendments are highlighted in Table 1.

2.5 Members are requested to approve the revised scoring, risk descriptions and rationales for scores for 3 of the Principal as proposed by Executive leads, detailed in Table 1 below.

Table 1

Principal risk Proposed Revision ID 7013 Strategic Aim 1: Quality Sub Aim 1.1 Safety Culture Keep our patients safe in our care putting their needs above all else Be assured about patient safety through; o ward accreditation o oversight of safe staffing o adoption of best practice at care handovers o daily safety briefings o compliance with WHO checklist

Change to Risk Description - There is a risk that the Trust will not be able to meet (and evidence) compliance with regulatory and professional standards and may not be able to consistently deliver high quality compassionate care to patients. This is due to; ongoing recruitment challenges, high use of temporary staff, the inability to provide essential clinical training and the inability to affect historic culture and behaviour. Change to rationale but score remains the same 5(c) x 3(l) = 15 Rationale: Likelihood has been scored at 3 as occurring at least monthly , consequence has been scored at 5 because the Trust continues to report a significant number of incidents that result in moderate - severe harm and death

ID 7014 Strategic Aim 1: Quality Sub Aim 1.2 Strong Governance Be fully open and transparent with our staff Ensure timely rapid learning when things go wrong Improve how we manage our risks and weaknesses to make us safer Make sure we work consistently to provide safe care Risk Description The current governance structure is not optimally aligned to ensure the capacity and capability to adequately escalate and cascade

Changes to Rationale & Score – originally scored as a 5(c) x 4 (l) = 20 as the consequence was linked to safety and SIs this has now been tied into the risk above – risk score and rationale for this risk now relate to compliance as per the risk description Revised rationale Likelihood has been scored at 4 as the risk is likely the consequence has been scored at 4 major as delivery of strong integrated governance has been raised as a significant concern by the CQC with an associated 29a warning notice still in place.

5

patient safety, clinical effectiveness, patient experience and performance concerns and to deliver the associated regulatory governance standards. ID 6752 Strategic Aim 4: Resources Sub aim 4.4 Ensure investments in technology and facilities improve experience for staff and outcomes for patients Risk Description Risk that the Trust is not able to access or prioritise capital resources to enable it to ensure that service continuity is maintained, statutory regulations are adhered to and services are improved through the use of technology.

Changes to score The risk score has been proposed for increase from 4(c) x 3(l) = 12 to 4(c) x 4 (l) = 16 Rationale as there is no decision on emergency capital bid as at 12 October 2018. £1.5m+ pressure on Mortuary works as well as £0.5m on MRI contingency and £1m on St Michael's Hospital. Partly offset by underspends on Cath Lab and E Notes projects. Risks also remain on medical capital equipment and fire safety. Risk relates to the breach of the Capital Resource Limit.

2.6 In order to align with revised Executive Leads’ portfolios, it is proposed that the Principal risk relating to Strong Governance (Strategic sub-aim 1.2) is assigned to the Chief Nurse.

2.7 The principal risks have been displayed in a ‘heat map’ to provide members with a profile of Principal risks to the delivery of strategic objectives. Each risk is represented by two circles plotted on the 5x5 risk matrix; the blue circle notes the current risk score and the grey represents the target risk score. Arrows show the direction of planned risk reduction.

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7

Risk Risk Owner/ Executive Lead

Action Taken Date to achieve reduced/ target risk score

4301 – Variability in ED Performance

Toby Slade – CD Urgent and Emergency Care Chief Operating Officer

Increased in Score – Risk Score increased from 16-20 - Crowding increasing and department now experiencing sustained pressure on subsequent days not allowing for recovery. The Team consistently uses the Emergency Department Crowding Standard Operating Procedure (SOP), to maintain patient safety. ED escalation triggers have been developed and four hourly board rounds are being undertaken. 2018/19 Winter Plan currently being tested system wide.

To be reviewed December 2018 following the implementation of the Winter Plan.

6443 – Patient monitoring in the Emergency Department

Owen McCormack – ED Consultant Chief Operating Officer (COO)

Increased in Score- This score was reduced to 12 in August 2018 by the COO as a result of agreement in principal to purchase new monitoring equipment. As this equipment is not yet in place the score has been increased to 15 until the equipment is purchased and installed.

December 2018

6655 Lack of ICU beds

Ken Mccune - Consultant Vascular Surgeon Chief Operating Officer

Risk Closed - at COMCELL it was agreed to amalgamate this risk into the ITU capacity/flow risk 6365 as this would apply to specialties access

6827 - Management of Spinal Patients referred to Therapy services

Vicki Slade – NAHP Service Improvement Medical Director

Reduced in Score – This score was reduced from 15 to 12 – As a network solution to support the management of these patients has been agreed

6587 – Implications of modernising radiotherapy NHS England consultation

Louise Hunt – Cancer Services Manager Director of Strategy & Performance

Reduced in Score – Risk score reduced from 15 to 12 by the Director of Strategy and Performance following discussion with the Risk Owner – on the basis that there is uncertainty on the timescales associated with NHSE’s consultation outcome decision.

6855 – Delayed/failed discharges resulting from sub-standard NEPTS ambulance performance

Nick Masters – Patient Transport Manager Chief Operating Officer

Reduced in Score – Risk reduced from 15 to 10. This risk was added and initially scored at 15. This was challenged whilst the likelihood of the risk occurring remains almost certain (5) as RCHT have limited control on the delivery of the EZEC contract. The consequence/ impact on the Trust is being controlled through the use of the Life star contract limiting the impact to a minor (2) to the Trust of failed discharges.

8

3.4 In order to provide greater visibility of the current mitigation and planned actions in place for the most significant risks, a ‘deep dive’ data extract of all risks scoring 16 or more has been presented at each Board level Committee. The aim of this is to provide greater assurance that management of these risks is appropriate.

3.5 Table 4 below shows the number of risks on the Corporate Risk Register by the Lead Director responsible for the risk:

Table 4 Risks Assigned to Executive Lead

3.6 Table 5 shows the number of risks on the Corporate Risk Register against the Trust Strategic Objective in order to provide clear linkage with the Board Assurance Framework:

Table 5 Risks Linked to Strategic Objective

3.7 Table 6 below shows the number of Corporate Risk Register risks on the by relating primary Assurance Committee responsible for oversight of the risks. Please note,

0

2

4

6

8

10

12

Chief Nurse ChiefOperatingOfficer

Director ofFinance

Director ofHR & OD

MedicalDirector

Corporate Risks Assigned to Executive Lead

Chief Nurse

Chief Operating Officer

Director of Finance

Director of HR & OD

Medical Director

0

5

10

15

20

25

30

Quality: Toprovide

compassionate,safe, effective

care

Resources: Makethe best use of allof our resources

People: Attractdevelop and

retain excellentstaff

Corporate Risks Linked to Strategic Objective

Quality: To providecompassionate, safe, effectivecare

Resources: Make the best useof all of our resources

People: Attract develop andretain excellent staff

9

some risks are presented to multiple Committees to facilitate sharing of risk information where multiple impacts have been identified.

Table 6 Risks by Assuring Committee

3.8 The October Corporate Risk Register dashboard lists 40% (n.12) of risks with no recorded actions and 3.3% (n.1) of risks with overdue actions. In response, the Risk Manager has carried out a targeted review of all risks held on the Corporate Risk register to improve the recording and management of all planned mitigating actions. This project has led to a 100% reduction in the total number of risks with no planned mitigating actions with targeted action plans for all risks held on the Corporate Risk Register.

3.9 Two risks have actions have breached their anticipated completion dates and risk owners are being supported to ensure that actions are completed within expected timescales.

3.10 The Corporate Risk Register and Principal risks are provided to the Shaping Our Futures (SOF) Provider Board on a quarterly basis. Risks held by the Trust which impact on the system are included in the System Wide Risk Register along with those held by partner organisations.

0

5

10

15

20

25

30

FIC POD QAC

Corporate Risks by Primary Assuring Committee

FIC

POD

QAC

10

4 Risk Management Improvement Plan

4.1 Following the findings of two internal audits, the Trust implemented a Risk Management Improvement Plan, aimed at improving both the risk management approach and associated processes within the Trust.

4.2 A range of work streams were identified to address this:

Review risk management strategy and policy and associated documentation with focus on simplifying the approach. The revised Risk Management Strategy was approved by the Board in June 2018. Communication and support to key staff within divisions has taken place;

Strengthening the management of risk at a senior level; an Executive Risk review, dedicated Board risk and assurance session and risk workshop was delivered to the Operational Executive Group. Attendance at the Divisional Governance Boards to present the revised approach to risk;

Cleansing the current risk register and working with divisional and specialty teams to ensure their Risk Registers reflect their wicked issues. Using a ‘top down’ approach, the Corporate Risk Register underwent an intensive cleanse. Following this, risks scoring 12 have been reviewed with risk owners. The implementation of the revised clinical structure will allow Care Groups to have improved visibility of their risks in order to carry out data cleanses in conjunction with the Risk Management Team; monthly Risk Surgeries are planned to increase support and training to further cleanse the Risk Registers ;

Provide “Board to Ward” clear line of sight through alignment of BAF, Corporate Risk Register and Ward Based Risks. All risks held on the Corporate Risk Register and scoring 12 have been aligned to the Trust’s strategic objectives, to provide greater line of sight. Linkage of the remaining risks will take place as part of the data cleanse in conjunction with Care Groups;

Ongoing risk management advice and coaching for key support posts. A forum has taken place with key governance staff in the Trust to strengthen understanding of the revised approach to risk management. Monthly risk surgeries are being scheduled with the interim care group leaders ;

Deliver organisational wide training on the basics of risk management through an accessible rapid roll out programme. A training needs analysis has been carried out to identify requirements for organisation-wide staff training. An integrated governance approach to training is currently under consideration.

5 Recommendations

5.1 The Board is recommended to:

Review the Board Assurance Framework Summary Report as at October 2018/19, and the more detailed single page format Board Assurance Framework report as at Appendix 1 and consider whether the principal risks are appropriately described and scored, and whether there is sufficient assurance that they are being effectively managed;

Approve proposed revisions to Principal risk ;

Note the Corporate Risk Register (risks currently scoring 15 or more or risks that have a

trust wide impact scoring 12);

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Note the current position of the Risk Management Improvement Plan

Appendix 1 Single Page Format, Board Assurance Framework Appendix 2 Corporate Risk Register Dashboard October 2018 Bernadette George Director of Integrated Governance

14.2_Appendix 1 Corporate Risk Register Dashboard October 2018

Oct-18

Corporate Risks Register and Principal Risks Oversight Dash Board

Lead Director / Division Current Date risk

Identified ≤6 8 9 10 12 15 16 ≥20 # Dates to achieve target risk score Strategic Objectives Primary Assuring Committee CQC Domain

QAC 7013 Quality Strategic Aim 1.1 Safety Culture ‐ Compliance with regulatory standards Chief Nurse 15 Oct‐18 Quality: To provide compassionate, safe, effective

care

Quality Assurance Committee Caring, Effective, Responsive,

Safe, Well Led

QAC 7014 Quality Strategic Aim 1.2 Strong Governance ‐ Governance structure is not optimally aligned Medical Director 16 Oct‐18 Quality: To provide compassionate, safe, effective

care

Quality Assurance Committee Effective, Responsive, Safe, Well

Led

QAC 7016 Quality Strategic Aim 1.3 Tackling Delay ‐ Winter period resilience Chief Operating Officer 16 Oct‐18 Quality: To provide compassionate, safe, effective

care


Led

POD 7017 People Strategic Aim 2.1 Safety Culture ‐ Lack of a coherent People Strategy Director of HR & OD 16 Oct‐18 People: Attract develop and retain excellent staff People & Organisational

Development Committee

Caring, Effective, Responsive,

Safe, Well Led

POD 7018 People Strategic Aim 2.2 Safety Culture/Strong Governance ‐ Staff engagement Director of HR & OD 12 Oct‐18 People: Attract develop and retain excellent staff People & Organisational


Caring, Effective, Responsive,

Safe, Well Led

POD 7019 People Strategic Aim 2.3 Safety Culture ‐ Develop Leadership cabability Director of HR & OD 12 Oct‐18 People: Attract develop and retain excellent staff People and Organisational


Effective, Responsive, Safe, Well

Led

FIC 7020 Partnership Strategic Aim 3.1 Tackling Delay‐ Insufficient Health and Social Care Provision outside of RCHT Director of Strategy & Performance 16 Oct‐18 Partnership: Offer integrated care as close to

home as possible

Finance Committee Caring, Effective, Responsive,

Safe, Well Led

FIC 7021 Partnership Strategic Aim 3.2 Strong Governance ‐ County Wide Children's Service Planning Director of Strategy & Performance 12 Oct‐18 Partnership: Offer integrated care as close to

home as possible

Finance Committee Caring, Effective, Responsive,

Safe, Well Led

FIC 7022 Partnership Strategic Aim 3.3 Tackling Delay ‐ Organisational Digital Strategy Director of Strategy & Performance 15 Oct‐18 Partnership: Offer integrated care as close to

home as possible

Finance Committee Effective, Responsive, Well Led

FIC 7024 Partnership Strategic Aim 3.4 Safety Culture/Strong Gov ‐ Engagement with research Director of Strategy & Performance 6 Oct‐18 Partnership: Offer integrated care as close to

home as possible


FIC 6749 Resources Strategic Aim 4.1 Resources Strong Gov/Safety Culture/Tackling Delay ‐ Achieve Financial Target Director of Finance 20 Oct‐18 Resources: Make the best use of all of our

resources


FIC 6751 Resources Strategic Aim 4.2 Safety Culture/Strong Gov/Tackling Delay Identify and Delivery Recurrent Savings Director of Finance 12 Oct‐18 Resources: Make the best use of all of our

resources


FIC 7029 Resources Strategic Aim 4.3 Strong Gov/Tackling Delay ‐ Transformational schemes within the health economy Director of Finance 12 Oct‐18 Resources: Make the best use of all of our

resources


FIC 6752 Resources Strategic Aim 4.4 Tackling Delay ‐ Risk of not accessing or prioritising capital resources Director of Finance 16 Oct‐18 Resources: Make the best use of all of our

resources


QAC 4301 Variability in ED performance Chief Operating Officer 20 Jun‐12 Dec‐18Quality: To provide compassionate, safe, effective

care

Quality Assurance Committee Effective, Responsive, Safe

QAC 1101 Lack of appropriate CAMHS support for young people admitted with mental health issues Chief Nurse 20 May‐15 Sep‐18Quality: To provide compassionate, safe, effective

care

Quality Assurance Committee Responsive, Well Led

QAC 6418 Referral to Treatment Performance Chief Operating Officer 20 Aug‐17 Oct‐18Quality: To provide compassionate, safe, effective

care

Quality Assurance Committee Responsive

QAC 6487 High Stroke Mortality Rate in comparison to benchmarks Medical Director 16 Oct‐17 Sep‐18Quality: To provide compassionate, safe, effective

care

Quality Assurance Committee Responsive, Safe

QAC 3744 Equipment not fit for purpose (ED CT dual slice head scanner) Chief Operating Officer 16 Oct‐11 Mar‐19Quality: To provide compassionate, safe, effective

care

Quality Assurance Committee Effective

QAC 6245 Serious Incident Administration and non compliance with CQC Regulation 12 Medical Director 16 Apr‐17 Jul‐18Quality: To provide compassionate, safe, effective

care

Quality Assurance Committee Responsive, Safe, Well Led

QAC 4523 MRI capacity (particularly inpatients) ‐ ageing MRI 1+2 scanners, increased demand Chief Operating Officer 16 Dec‐12 Mar‐19Quality: To provide compassionate, safe, effective

care


QAC 4966 High acuity patients will not be able to be treated in a high dependency area due to small resus area Medical Director 16 Sep‐13 Sep‐18Quality: To provide compassionate, safe, effective

care, Resources: Make the best use of all of our


QAC 5536 Failure to comply with Duty of Candour regulations as a result of low staff awareness and performance management Medical Director 16 Mar‐15 Dec‐18Quality: To provide compassionate, safe, effective

care

Quality Assurance Committee Caring, Responsive, Well Led

FIC 6863 PAS Financial Risk Director of Finance 16 Jul‐18 Sep‐18Resources: Make the best use of all of our

resources


FIC 6874 CT scanner and lasers end of life Director of Finance 16 Jul‐18 Oct‐18Quality: To provide compassionate, safe, effective



QAC 6780 Medical Equipment Maintenance (medicine and ED) Medical Director 16 Apr‐18 Sep‐18Quality: To provide compassionate, safe, effective



QAC 6365 Patient Flow ‐ Delayed discharges from Critical Care Chief Operating Officer 16 Jan‐18 Oct‐18Quality: To provide compassionate, safe, effective

care


QAC 6849 Lack of flow in MAA due to use of area for inpatient beds Chief Operating Officer 15 Jun‐18 Sep‐18Quality: To provide compassionate, safe, effective

care

Quality Assurance Committee Caring, Effective, Responsive,

Safe

FIC 6882 Lack of a Digital Strategy and Roadmap in RCHT Director of Finance 15 Jul‐18 Sep‐18Quality: To provide compassionate, safe, effective


Finance Committee Effective, Safe, Well Led

QAC 6903 Patients transferred from MAU to oncology assigned to oncologist without being seen Medical Director 15 Jul‐18 Sep‐18Quality: To provide compassionate, safe, effective

care

Quality Assurance Committee Caring, Effective, Safe

QAC 6766 Delayed or not sent discharge summaries Medical Director 15 Mar‐18 Dec‐18Quality: To provide compassionate, safe, effective



QAC 6770 Inability to assure whether prospectively booked follow‐up patients are booked within their To Be Seen Date Chief Operating Officer 15 Mar‐18 Dec‐18

Quality: To provide compassionate, safe, effective

care

Quality Assurance Committee Safe

POD 5609 Mandatory Training and PDR Compliance Director of HR & OD 15 Jun‐15 Jun‐18Quality: To provide compassionate, safe, effective

care

People and Organisational


Caring, Effective, Safe

QAC 5930 Provision of the cervical cancer screening programme via PHE contract for Cornwall and Plymouth patients Chief Operating Officer 15 Apr‐16 Nov‐18

People: Attract develop and retain excellent staff,



Led

QAC 6170 Breaches of complaints timescales Chief Nurse 15 Jan‐18 Aug‐18Quality: To provide compassionate, safe, effective

care


QAC 6278 Respiratory outpatient capacity Chief Operating Officer 15 May‐17 Oct‐18Quality: To provide compassionate, safe, effective

care

Quality Assurance Committee Responsive, Safe

QAC 6685 N3 Wide Area Network Ceasing to exist Director of Finance 15 Feb‐18 Sep‐18Quality: To provide compassionate, safe, effective

care

Quality Assurance Committee Safe

QAC 6691 ED Oceano ‐ missing clinical information from ED & MIU attendance summaries sent to GPs Medical Director 15 Feb‐18 Aug‐18Quality: To provide compassionate, safe, effective

care


QAC 6730 Outpatient Clinic Letters delay Chief Operating Officer 15 Mar‐18 Dec‐18Quality: To provide compassionate, safe, effective



QAC 6443 Patient Monitoring in the ED Chief Operating Officer 15 Aug‐17 Dec‐18Quality: To provide compassionate, safe, effective

care


QAC 6584 NICE Quality standard 158 ‐ Critically ill patients may not receive adequate rehabilitation physiotherapy Chief Nurse 15 Jan‐18

Due for Review

October 18


care People: Attract develop and retain excellent


POD 3093 Improving communication and engagement with staff Director of HR & OD 12 Aug‐10 Due for Review

October 18

People: Attract develop and retain excellent staff, People and Organisational


Caring, Well Led

POD 5821 Culture and leadership Improvement Director of HR & OD 12 Jan‐16

2Due for Review

October 18

People: Attract develop and retain excellent staff, People and Organisational


Caring, Well Led

QAC 6827 Reduced Management of Spinal Patients referred to Therapy servicess Medical Director 12 May‐18 Nov‐18Quality: To provide compassionate, safe, effective

care


QAC 6587 Reduced Implications of modernising radiotherapy NHS England consultation Director of Strategy and

Performance

12 Dec‐17 Sep‐18Quality: To provide compassionate, safe, effective

care

Quality Assurance Committee Effective, Responsive, Well Led

QAC 6855 Reduced Delayed/failed discharges resulting from sub‐standard NEPTS ambulance performance Chief Operating Officer 10 Mar‐18


care

Quality Assurance Committee Effective, Responsive, Well Led

Key Indicates movement in the quarter; Diamond indicates current score; Circle indicates target risk score # Hash symbol column indicates no. of overdue actions Indicates no open actions. Indicates Principal Risk held on BAF Indicates closed risk or reduced score and removed from CRR

Principal Risks

Corporate Risk Register and Principal Risks

Closed Risks

Corporate Risk Register

Page 1 of 2

14.2_Appendix 1 Corporate Risk Register Dashboard October 2018

Oct-18

Corporate Risks Register and Principal Risks Oversight Dash Board

Lead Director / Division Current Date risk

Identified ≤6 8 9 10 12 15 16 ≥20 # Dates to achieve target risk score Strategic Objectives Primary Assuring Committee CQC Domain

Key Indicates movement in the quarter; Diamond indicates current score; Circle indicates target risk score # Hash symbol column indicates no. of overdue actions Indicates no open actions. Indicates Principal Risk held on BAF Indicates closed risk or reduced score and removed from CRR

Corporate Risk Register and Principal Risks

QAC 6655 Closed Lack of ICU beds Chief Operating Officer 16 Dec‐17 Oct‐18Quality: To provide compassionate, safe, effective

care


Page 2 of 2

Date 18.09.18 BAF Template 2018/19

QAC CN

Risk rating Likelihood Consequence Total

Initial 4 5 20

Current 3 5 15

Appetite 2 5 10

Approach

Sources of

assurance

Rec'd/ RAG

AMBER

AMBER

RED

GREEN

GREEN

AMBER

AMBER

AMBER

AMBER

AMBER

SCORE: A M J J A S O N D J F M

Likelihood 3

Consequence 5

Risk rating 15

Tolerance 12 12 12 12 12 12

QEWs Ward to Board Assurance Framework

Policy for the Governance of External visits (including Inspections and Peer Reviews) and

Accreditation

Duty of Candour (DoC) Compliance

Gaps in assurance Positive assurances received

CQC Scrutiny Group meetings and the associated Integrated Action Plan

Matrons rounds & feedback mechanisms

Quanta audit and reporting schedule

Evidence of Team Improvement Meetings

Learning from incidents and Safety Huddles

Clinical Effectiveness group reports on external visits recommendations and

associated action plan delivery

Daily "Team Improvement Meetings" Twice yearly establishment review reported to Trust Board. Monthly unify report

"Safety Huddles" Monthly WHO reports and QIDB reporting structure

Friends and Family Test (FFT) Ward Accreditation reports and action plans

Ward Accreditation Programme - Aspire

Twice yearly "CQC Self Assessment Process" Quality Governance Group reports

Safe Staffing - Systems and processes daily and twice yearly establishment review CQC self assessment reports

Quality Improvement Delivery Board reports

Date Risk Reviewed

Rationale: Likelihood has been scored at 3 as occurring

at least monthly. Consequence has been scored at 5

because the Trust continues to report a significant

number of incidents that result in moderate - severe

harm and death TREAT

Key controls to mitigate threat:

Safe, Effective, Caring Responsive & Well -Led

Links to SOF

Planned Care Board

A & E Delivery Board

Committee Providing Assurance Executive Lead

Strategic Aim 1: Quality - " To provide compassionate safe

effective care"

Delivery supports RCHT QIP Themes PRINCIPAL THREATS TO DELIVERY

1.1 Sub Aim

Safety Culture

Keep our patients safe in our care putting their needs above all else

Be assured about patient safety through;

o ward accreditation

o oversight of safe staffing

o adoption of best practice at care handovers

o daily safety briefings

o compliance with WHO checklist

Safety Culture Current Principal Risk

Strong Governance There is a risk that the Trust will not be able to meet (and evidence)

compliance with regulatory and professional standards and may not be

able to consistently deliver high quality compassionate care to patients.

This is due to; ongoing recruitment challenges, high use of temporary

staff, the inability to provide essential clinical training and the inability to

affect historical culture and behaviour.Tackling Delay

CQC Domain

Current Performance

The Trust remains in special measures although improvement is noted in the report received

from the 29a inspection visit undertaken in June 2018

Additional Comments

CQC 29a Warning Notice still in place - report due in September 2018

CQC Comprehensive Assessment to be completed in September and report due November /

December. CQC Integrated Action plan still has 151 outstanding actions 71 of which are rated

as red

Safer Care SOP not in date

Ward Accreditation not delivered all areas of the Trust (in-patient wards only)

Other clinical areas and departments not using standardised safety huddle (part of Safety

Culture work plan for 2018

CQC report received regarding 29a warning notice and improvements in quality are noted reducing

the scope of the warning notice

Section 29a dashboard for Maternity & WHO Checklist

All wards undergoing 2nd phase of Ward Accreditation have improved or maintained their scores

Positive NHSI external review for End of Life Care

Positive 3 month performance of in-patient Friends & Family Test results

Gaps in control

Policy for the Governance of External visits (including Inspections and Peer Reviews) and

Accreditation is a new policy and therefore is not fully embedded as business as usual

Treatment escalation planning is not consistent and poor compliance with the Treatment

Escalation Plan Policy

Actions being taken to address gaps in control / assurance

CQC Integrated Action plan progress continues to be scrutinised weekly

CQC outstanding actions escalated to Executive team meetings and discussed on a weekly basis to

drive increased executive ownership and oversight

Duty of Candour compliance Improvement Plan

Ward Accreditation to be rolled out to ED / Maternity/ ITU / Paeds in 2018. Ward Accreditation to be

rolled out through day case areas and outpatients in 2019

Roll out of non clinical area handovers as part of safety culture programme

Education & audit programme to be developed for treatment escalation planning

0

0.5

1

A0

20

40

A M J J A S O N D J F M


QAC MD


Initial 5 5 25

Current 4 4 16

Appetite 3 4 12

Approach

Rec'd/ RAG


Likelihood 4

Consequence 5

Risk rating 20

Tolerance 12 12 12 12 12 12

Internal Audit Report, Risk Management Arrangements

CQC report received regarding 29a warning notice improvements notes

Quality Assurance Group reports

Risk Management System (Datix) - Infrastructure issues

Divisional Governance Frameworks not fully embedded

Clinical Governance Group - not fully embedded / aligned to Board reporting

Divisional and CD governance resource and full engagement at Divisional and Corporate level

No clear Accountability Framework

Timeliness of incident management and backlog

Current governance structure and capacity

Risk Management Improvement Programme -Datix infrastructure work

Embed Divisional Governance Framework

Embed Clinical Governance Group

Develop clear Accountability Framework

Hard Reset for Governance to clear backlogs

Duty of Candour Compliance Improvement Plan

Develop a Trust Learning Framework

Additional posts have been created to support governance and restructuring of the governance function

Gaps in Control Actions being taken to address gaps in control / assurance

Shared Learning Events

Duty of Candour performance

Safe, Effective, Responsive & Well- Led

Integrated Risk Management Information System - Datix

Duty of Candour Compliance Improvement Plan

Quality Improvement Delivery Board reports

Links to SOF

Provider Board

Date Risk reviewed

Key controls to mitigate threat: Sources of assurance



TREAT

Divisional Governance & Performance Framework - linked to the "Ward to Board Assurance

Framework"

Quality Governance Strategy & Plan

Friends and Family Test (FFT)

Delivery of "Well Led Review" Action Plan

Governance 29a Warning Notice(WN) - although improvement noted - WN remained in place

Current Performance Additional Comments

Quality Improvement Delivery Board - Governance Work Stream Improvement Plans &

associated project management support

Rationale: Likelihood has been scored at 4 as the risk is likely

the consequence has been scored at 4 major as delivery of

strong integrated governance has been raised as a a

significant concern by the CQC with an associated 29a

warning notice still in place.

Additional capacity/ resource to improve the quality of clinical governance centrally

Internal Audit Report, Divisional governance arrangements

Corporate & Divisional Governance Newsletters

CQC 29a Warning Notice relating to governance

Duty of Candour Compliance - Historic Assurance


effective care"


1.2 Sub Aim

Strong Governance

Be fully open and transparent with our staff

Ensure timely rapid learning when things go wrong

Improve how we manage our risks and weaknesses to make us safer

Make sure we work consistently to provide safe care

Safety Culture

The current governance structure is not optimally aligned to ensure the

capacity and capability to adequately escalate and cascade patient safety,

clinical effectiveness, patient experience and performance concerns and to

deliver the associated regulatory governance standards.

Strong Governance

Current Principal Risk

Tackling Delay

CQC Domain

0

0.5

1

A0

10

20

30



QAC COO


Initial 5 4 20

Current 4 4 16

Appetite 3 3 9

Approach

Rec'd/ RAG


Likelihood 4

Consequence 4

Risk rating 20

Tolerance 9 9 9 9 9 9

As at September 2018 IPR; RTT = 80.9% A & E 83.4%,Cancer - Quarterly Standards met

Critical care occupancy levels 99% (124% L3 and 65%L2)

Diagnostic performance 90%

Planned Care Board reports

SDEC KPI Reports

ICNARC reports

Five Steps to Safer Surgery monthly audit reports


RTT performance

Cancer performance

Critical Care occupancy levels

Diagnostic performance

Winter planning arrangements

CQC report received regarding 29a warning notice and improvements in critical care discharges

noted

Proposed Principal Risks

Rationale: Likelihood has been scored at 4 as the winter

resilience risk is likely Consequence has been scored as

4 major , as a result of quality of care provided and

regulatory compliance impact.

There is risk that the Trust will not be resilient over the winter period, this

will adversely impact on the quality of care delivered and the overall

patient experience leading to cancelled or delayed treatment. Impacting

the Trusts ability to deliver a range of regulatory performance standards

including the A & E 4 hour standard, the cancer, diagnostics & RTT

standards.

Strong Governance

Outpatient Transformation Work is not yet impacting

RTT recovery outsourcing plans are not delivering required volumes

RTT Recovery Plans at specialty level

Cancer Recovery Programme

Critical Care Discharge Improvement Plan

Diagnostic Recovery Plan

SAFER work stream - to expedite discharges

Creating additional community bed capacity & packages of care

Exercise to test Winter Plans

OPD Transformation project is being refreshed to deliver clear KPI's

Harm Review Panel / oversight


Same Day Emergency Care Initiative

"Bronze Control" daily to support flow

Actions being taken to address gaps in control / assuranceGaps in control

Critical Care Discharges Improvement Plan

Quality Improvement Delivery Board (QIDB) - Tackling Delays Work stream - Project

resource dedicated to delivery

Safe, Effective , Responsive & Well-Led


Tackling Delay

CQC Domain

Links to SOF

QIDB reports

Referral to Treatment (RTT) & Cancer - Improvement Plan project resource

Integrated Performance Report


Outpatient Transformation Work stream- Project resources dedicated to delivery

RTT & Cancer Performance reports

SAFER care bundle project work stream

A& E Delivery Board

Planned Care Board



Ophthalmology and Cardiology Improvement Plans

A& E Delivery Board reports


effective care"

Delivery supports RCHT QIP Themes

Performance Metrics - Performance Assurance Framework

TREAT

PRINCIPAL THREATS TO DELIVERY

1.3 Sub Aim

Tackling Delays

Achieve the agreed standards for emergency and planned care

Deliver cancer services in line with cancer standards

Deliver an improved outpatient service

Increase the proportion of patients who receive same day emergency care

Safety Culture

Date Risk reviewed

0

0.5

1

A0

20

40



P&OD HRD


Initial 5 4 20

Current 4 4 16

Appetite 2 4 8

Approach

Rec'd/ RAG


Likelihood 4

Consequence 4

Risk rating 16


As at September 2018 IPR; Mandatory training compliance 82.6%

Appraisal completion 75.4%

Sickness rate 3.87%

Turnover Rate 10.5% (3% Junior Doctor rotation)


Gaps in control

Proposed Risk


Absence of a fully aligned , comprehensive "People Strategy" that draws together the

HR, OD and Engagement components that are currently sitting in disparate documents

Development of a fully aligned People Strategy

Delivery of the Resourcing Plan

ESR review and data validation exercise

Agency controls need reviewing

Develop enhanced performance monitoring and reporting mechanisms for all HR, OD and

Engagement KPI's


Safe, Effective, Caring, Responsive & Well-

Led

There is a risk that the lack of a coherent aligned "People Strategy" for

the Trust will result in the inability to provide the right people in the right

place at the right time for the right cost'; posing a significant risk to the

Trust's ability to meet its care, financial and performance obligations.

Junior Doctor Contract - exception reporting

Agency Staff usage remains high

Vacancy levels are high

Mandatory training compliance is not being met

ESR data quality and functionality is questionable


Staff training records -monthly

Delivery against the Resourcing Plan

Staff training

Junior Doctor - Action Plans to deliver themes from exception reports

Resourcing Plan

Learning & Development Strategy

Finance Committee reportsStaff Health & Wellbeing Strategy

ESR reports

Human Resources Dashboard - monthly


Operational Workforce Group reports

Workforce Plan is targeting recruitment to reduce vacancies, developing new roles to

deliver the functions of hard to recruit to posts

Staff Health & Wellbeing Group reports

Operational Work Force Group - Monitors vacancy levels and use of agency staff &

reports to the Finance Committee

People and Organisational Development Committee reports


Date Risk reviewed

Rationale: Likelihood has been scored at 3

Consequence has been scored at 5 because there is a

considerable risk of the current recruitment and

resourcing plan not delivering. TREAT

Strategic Aim 2: People - " Attract, develop and retain

excellent staff "


2.1 Sub Aim

Ensure we recruit and retain staff, who have the right skills and

experience to provide safe, effective care.

Safety Culture

Strong Governance

Tackling Delay

CQC Domain

Links to SOF

A& E Delivery Board

Planned Care Board

0

0.5

1

A0

20

40



P&OD HRD


Initial 4 4 16

Current 3 4 12

Appetite 2 4 8

Approach

Rec'd/ RAG


Likelihood 3

Consequence 4

Risk rating 12


As at September 2018 IPR; Mandatory training compliance 82.6%

Appraisal completion 75.4%

Sickness rate 3.87%

Turnover Rate 10.5% ( 3% Junior Doctor rotation)

Gaps in assurance

Proposed Risk

Positive assurances received

Absence of a fully aligned , comprehensive "People Strategy" that draws together the HR, OD

and Engagement components that are currently sitting in disparate documents

Development of a "Recognition Component" to form part of the "People Strategy"

Finalise the "OD & Engagement Component " to form part of the "People Strategy"

Gaps in control Actions being taken to address gaps in control / assurance


Communication & Engagement Strategy & additional senior HR capacity

Outputs from "Improve Well " initiative Friends and Family Test (FFT)

Team Improvement Meeting daily rolled out to all areas

"Improve Well" Application introduced

Staff Survey results

Gaps in communication and engagement

Absence of a "Recognition Component " to form part of the "People Strategy"

An accepted "OD Component " to form part of the "People Strategy"

Gaps in communication and engagement

Delivery of actions arising from Medical Engagement Survey (MES)Freedom to Speak up Guardians & Champions established

Delivery of actions arising from the National and Local Staff SurveysBoard Walkabouts

NHSI Cultural Survey - SCORE results & Action Plan progressExecutive leadership to Improving Working Lives Group

Improving Working Lives Group reports

NHSI Culture Survey - SCORE findings and Action Plans


Rationale: Likelihood has been scored at 3 Consequence

has been scored at 4 as staff engagement is a major risk .

TREAT

CQC Domain

Links to SOF

There is a risk that staff do not know about or feel that they are able to

contribute to the continued improvement of the organisation caused by

insufficient communication and engagement of staff in decision making,

linked to the pace of change required. This could adversely affect the

improvements planned to safety, governance, unnecessary delays and the

day to day delivery of high quality and compassionate care.

Medical Engagement Survey (MES) findings and Action plans


People and OD Committee reportsWorkforce Plan

Date Risk reviewed

Strategic Aim 2: People - " Attract, develop and retain excellent

staff "


2.2 Sub Aim

Create an open, learning environment where all staff feel valued and able to

contribute to our Quality Improvement Plan

Safety Culture

Safe, Effective, Caring, Responsive & Well -

Led

Strong Governance

Tackling Delay

A& E Delivery Board

Planned Care Board

0

0.5

1

A0

20

40



P&OD HRD


Initial 4 4 16

Current 3 4 12

Appetite 2 4 8

Approach

Rec'd/RAG


Likelihood 3

Consequence 4

Risk rating 12


Recognition that current structures are not working

HR KPI's, financial KPI's and NHS constitutional standards are not being delivered consistently


Absence of a fully aligned , comprehensive "People Strategy" that draws together the HR, OD and

Engagement components that are currently sitting in disparate documents

Finalise the "OD & Engagement Component " to form part of the "People Strategy"

Restructuring of the Divisions to increase leadership capacity and capability. Create a flatter hierarchy to support

leadership cultural development.

Recruit to new roles to further enhance leadership capacity and capability

Gaps in assurance



An accepted "OD Component " to form part of the "People Strategy"

Leadership culture

Leadership capability

Delivery of the Lead & FMLM Programmes Ward Accreditation Programme

Leadership training - key management roles - LEAD & FMLM Programmes

New Executive leadership post created to drive culture and leadership capability

Workforce Plan

Well- Led & Use of Resources- delivery of Action PlanWell Led Assessment/ Review

LEAD programme - completed by key staff groups in leadership rolesLearning & Development Strategy

Ward Accreditation reportsBoard Development Programme


Rationale: Likelihood has been scored at 3 Consequence has

been scored at 4 because leadership capability is a major risk

hence the restructuring plan.

TOLERATE/ TREAT

Performance against the Workforce PlanFriends and Family Test (FFT)


People and OD Committee reports

Strong Governance

Tackling Delay

A& E Delivery Board

Planned Care Board

CQC Domain

Links to SOF

Date Risk reviewed

Strategic Aim 2: People - " Attract, develop and retain excellent

staff "


2.3 Sub Aim

Enhance our leadership capability to drive optimal patient care

Safety Culture Proposed Risk

Safe, Effective, Responsive & Well-Led

There is a risk that the Trust does not recruit to and develop the leadership

capability at the pace required to drive & deliver the Quality Improvement Plan &

deliver optimum patient care.

0

0.5

1

A0

20

40



TB DS&P


Initial 4 4 16

Current 4 4 16

Appetite 2 4 8

Approach

Rec'd/ RAG

RED

AMBER

RED

RED

AMBER

AMBER

AMBER


Likelihood 4

Consequence 4

Risk rating 16


‘Stranded’ (7 day+) and ‘superstranded’ (21day+) and DTOC data (which are effectively a

subset of these). We also have information on patients who are medically fit for discharge

(broader than DTOCs as includes tertiary patients, internal delays etc.).


1. Gold Command initiative has highlighted ability of the system to 'respond' - needs to be sustained.

Accountable Care System Plans

Scope of Sustainable Transformation Plan (STP) has increased - not fully aligned to existing

Programme Board remit.


1. Resetting of Organisational Strategy to clarify what RCHT is here to provide.

Executive Lead

The joint infrastructure is not generating service improvement at this point and the number of

patients inappropriate cared for in the acute environment has not reduced.

SOF Leadership Arrangements - Programme Director

SOF Governance Structures


"Tackling Delays" Work streams

A & E Delivery Board reports


Tackling Delays KPI reports


Frailty Strategy

Committee Providing Assurance

Sources of assurance

Safe, Effective , Caring , Responsive & Well-

Led

Rationale: Likelihood has been scored at 4. Consequence has

been scored at 4 because RCHT continues to accommodate

patients at the Treliske site who would be better cared for at

home or in the community. This can lead to harm and patient

deterioration.TREAT


Planned Care Board

A & E Delivery Board

Proposed Risk

Links to SOF

QIDB reports

Falls Work stream Falls & frailty KPI performance

Risk that acute primary, community and social care provision outside of the

Treliske environment is insufficient, meaning that patients do not always receive

care and support in the most appropriate therapeutic environment.

Provider Board - Committee in Common Arrangements - RCHT and CFT

Trust Board Assurance reports regarding progression of SOF

Date Risk reviewed

Strategic Aim 3: Partnership " Offer integrated care as close

to home as possible "


3.1 Sub Aim

Offer more acute services out of hospital and support locality teams to care for

frail and vulnerable people at home

Safety Culture

Tackling Delay

Strong Governance

CQC Domain

0

0.5

1

A0

20

40



TB DS&P


Initial 3 4 12

Current 3 4 12

Appetite 2 4 8

Approach

Rec'd/RAG

RED

RED

RED

AMBER

RED

AMBER


Likelihood 3

Consequence 4

Risk rating 12




There is a memorandum of understanding between RCHT, CFT and KCCG to work together to drive

improvement in healthcare pathways which feed into "One Vision" work streams e.g. Neurodevelopmental

pathway . The start of this work is the review mentioned previously

The "One Vision" programme is being led by Kernow Council & alternate delivery models are in

development by the Kernow Council

RCHT Management representative attends and exerts influence through the One Vision -Executive Board

Engagement on healthcare initiatives done via One Vision where appropriate E.g. Handi app promoted at

Royal Cornwall Show as part of "One Vision" engagement

NHS Kernow Clinical Commissioning Group (CCG) has Commissioned a review of children's

services across Cornwall and the Isles of ScillyGaps in assurance Positive assurances received

The joint infrastructure is not generating service improvement at this point

Trust Clinical Lead Identified

Links with One Vision and Local Maternity System Programme Board (LMS)

Provider Board reports

New Developmental Pathways Groups

"One Vision" Partnership Board reports & minutes

CHAMS Partnership Group

"One Vision" Executive Board reports & minutes

"One" Vision Strategy & performance


Systems Assurance Group reports & minutes


"One Vision" Partnership Board - Programme resources - meets quarterly

"One Vision" Executive Board - meets monthly

Action Plan to deliver " Facing the Future" & progress of delivery

One Vision Board


TREAT

Strategic Aim 3: Partnership " Offer integrated care as close to

home as possible "


3.2 Sub Aim

Implement "One Vision" for children's services

Safety Culture

Safe, Effective, Caring , Responsive & Well-Led

Risk that planning for county-wide children's services takes place without

the considered input of the Trust from the perspective of acute paediatric

care.

Strong Governance

Proposed Risk

Tackling Delay

CQC Domain

Links to SOF

Date Risk reviewed

Rationale: Likelihood has been scored at 3. Consequence

has been scored at 4 as failure to incorporate sufficient

clinical views is a possible risk with regard to the planning of

children's services.

0

0.5

1

A0

20

40



TB DS&P


Initial 5 3 15

Current 5 3 15

Appetite 4 3 12

Approach

Rec'd/RAG

AMBER

AMBER

AMBER

AMBER

AMBER

AMBER

AMBER


Likelihood 5

Consequence 3

Risk rating 15

Tolerance 12 12 12 12 12 12


Gaps in control

Joint Trust Cybersecurity Group & programme resources Cybersecurity reports

There have been a number of IM&T related serious incidents in 2018 that has extended the

fragility of the current IM&T infrastructure.

Absence of TMG sign off for annual CITS RCHT Programme Plan

Gaps in assurance

Strategy in development for completion by 30 September 2018

More effective connectivity to Annual Plan and contract requirements

New initiatives to be discussed at E Health Programme Board before agreement at TMG

Identify how TMG will sign off annual CITS Programme as part of Annual Plan

Interviewing for CCIO on 1 August 2018



CITS Management Board review of annual CITS RCHT Programme Plan

Lack of RCHT Digital Strategy

Ineffective communication of National digital requirements e.g. NHS Standard Contract 2017/19

- Service Conditions - NHS Mail Relay issue / SI

Lack of RCHT Executive oversight and prioritisation of new digital initiatives / 'innovations'

Absence of RCHT TMG sign off for annual CITS Programme Plan

Lack of RCHT Chief Clinical Information Officer (CCIO)

Lack of regular engagement with CDs and Clinical Divisions, nurses and therapies

Sources of assurance

PAS Project Board & project resources PAS Project Board reports

Nerve Centre Project Board & project resources Nerve Centre Project Board reports

Frailty Strategy HSCN Project Board reports + Programme Plan

Rationale: Likelihood has been scored at 5. Consequence

has been scored at 3 because it is established that there is

currently no Trust-wide Digital Strategy and that this

inevitably leads to system disconnects.

Training staff - Accredited 5 day change management methodology programme - 20

August 2018

Executive Lead

Date Risk reviewed

E Health Programme Board & programme resources

E Notes Project Board & project resources


TREAT

Effective, Responsive &

Well-Led

Falls Work stream

Strong Governance

Tackling Delay

Digital Transformation Board reports + Programme Plan

E Notes Project Board reports

E Health Programme Board reports + CITS Programme Plan


PMO - Being established to standardise methodology and reporting documentation Virtual

PMO established - July 2018

Strategic Aim 3: Partnership " Offer integrated care as close

to home as possible "


3.3 Sub Aim

Adopt a "Digital First " approach to system wide transformation

Safety Culture Proposed Risk

CQC Domain

Links to SOF

E Health Board Programme Board

Risk that the lack of an organisational Digital Strategy will mean that the

Trust's IM&T infrastructure will be disconnected, sub-standard and not

support excellent clinical care.

0

0.5

1

A

0

5

10

1

0

0.5

1

A0

20

40



TB DS&P


Initial 2 3 6

Current 2 3 6

Appetite 2 3 6

Approach

Rec'd/ RAG

AMBER

AMBER

AMBER

AMBER

AMBER

AMBER

AMBER


Likelihood 2

Consequence 3

Risk rating 6




CRN Regional Benchmark reports

Audit reports of research studies


Research is not fully embedded in all Directorates within the Trust

Research is de-prioritised at times of acute hospital pressure - to utilise Research Nurses for frontline

care

The Research Director and the Research Team continually promote research

The Medical Director is providing senior leadership and engagement to promote research

The Research Team schedule the programme to deliver the required activity across the year

Research Director has included research as a fundamental requirement in all Clinician's Job Descriptions

Proposed Risk

Governance Research Lead - Governance SMT meeting held monthly

Research Team's audit function to monitor status

Gaps in assurance

Dedicated research programmed activity (PA's)/time in Clinician's Job Plans RSMT reports and minutes

National Institute for Health Research's (NIHR) 7 High Level Objectives & the associated Trust Goals

CRN Performance Management Framework

Governance SMT reports and minutes

Research Director and full Research Team to embed research into all Clinical Teams & Directorates

Recruitment to trials is the responsibility of the Principal Investigator of the Research Project - this is

supported through the Research Nurse assigned to the project

Recruitment to clinical trials performance against target

Monthly CRN meeting & performance reports & minutes

Research Team's Business Continuity Plan Performance against NIHR 7 High level Objectives & Trust Goals


Research Senior Management Team (RSMT) meetings - weekly

Clinical Research Network ( CRN) meetings - monthly Research Development and Innovation - Annual report

Research Development and Innovation - Annual Business Plan


Effective, Responsive & Well-Led

Lack of clinical buy-in/engagement with research will result in patients not having

an opportunity to take part in trails that may enhance their quality of life / wellbeing

now or in the future.

Date Risk reviewed

Rationale: Likelihood has been scored at 2. Consequence has

been scored at 3 because there is currently an acceptable level of

R&D activity within the Trust, although R&D income has reduced in

recent months.TOLERATE

Strategic Aim 3: Partnership " Offer integrated care as close to

home as possible "


3.4 Sub Aim

Make services better by encouraging patient involvement in research

Safety Culture

Strong Governance

Tackling Delay

CQC Domain

Links to SOF

Clinical Research Network South West Peninsula (CRN)

Academic Health science Network (AHSN)

0

0.5

1

A0

20

40



FC CFO


Initial 5 5 25

Current 4 5 20

Appetite 2 5 10

Approach

Rec'd/ RAG


Likelihood 4

Consequence 5

Risk rating 20

Tolerance 10 10 10 10 10 10

Financial plan not being met at month 4



Internal audit assessment of design of enhanced financial controls

Relatively low Potential Productivity Opportunity in the Model Hospital and good feedback from NHSI

during Operational Productivity visit

Loan funding approved

Urgent need to invest in services

Tracking and delivery of financial benefits of quality improvement

Changes to regulatory requirements with financial implications

Unavoidable agency spend with urgent service developments.

A fully resourced CIP PMO


Service developments are scrutinised by Executive Directors to confirm need

Review of quality improvement benefits so that they are costed

Recruitment initiatives included overseas recruitment and rebranding

CIP PMO heavily supported by CFT

Effective, responsive & Well-Led

Use of Resources Framework

Proposed Risk

Risk that the Trust does not achieve its financial target which will result in

lost income, additional debt and a longer period of time to recover to a

breakeven position.

Capital spend is monitored through, The Capital Deliver Group a sub group of the Finance

Committee

Benefits realisation of projects not yet tested

Shortfall in savings schemes

Internal audit assessment of existence of enhanced financial controls as being satisfactory

although more assurance required on application

Agency spend has risen significantly year on year even though agency controls remain in place

The Trust submits monthly cash forecasts to NHSI so that the cash need is clear.

Transformational savings opportunities are identified through "Shaping Our Futures" programme

to manage system wide control totals to return the whole health economy to financial balance.

Work force approvals processes are in place to control recruitment of all posts including agency

and locum staff.

The Trust's Workforce Plan is targeting recruitment to reduce vacancies and therefore reduce

the use of / spend against agency and locum staff.

CIP PMO established and regular CIP meeting scheduled to scrutinise and challenge service

level plans and delivery to the plans

Finance reports to the Trust Board

Standing Financial Instructions and Standing Orders including clear financial controls measures. Internal audit reports - re financial controls and processes

Operational Workforce Group - scrutiny of agency expenditure

Annual External Auditors Report - Head of External Audit's Opinion Report on the Trust's

Annual Report and Accounts

Annual Report and Accounts



Monthly Divisional Performance Review Meetings , including financial performance and Cost

Improvement Plan (CIP) delivery.

Finance Committee(FC) monthly reports - Including management of risks to delivery of

the financial plan, CIP delivery , income, expenditure & capital expenditure

Scheme of Delegation, clear processes for investment requests and business case approval to

ensure scrutiny of benefits prior to approval.

Trusts monthly submission to NHSI - cash forecasts


Date Risk reviewed

Rationale: Likelihood has been scored at 4 as at month 4

financial plan was not being met Consequence has been

scored at 5 because of the financial value involved.

TREAT

Strategic Aim 4: Resources "To make the best use of all our

resources"


4.1 Sub Aim

Be a financially stable organisation

Safety Culture

Strong Governance

Tackling Delay

CQC Domain

Links to SOF

A& E Delivery Board

Planned Care Board

System - wide Saving Plan

0

20

40


Date 18.09.18 DRAFT BAF 2018/19

FC CFO


Initial 4 4 16

Current 3 4 12

Appetite 2 4 8

Approach

Rec'd/RAG

Gaps in control


Likelihood 3

Consequence 4

Risk rating 12

Tolerance 12 12 12 12 12 12 8 8 8 8 8 8

Savings plan is not being met


Shortfall in savings schemes at the Trust

Lack of savings that can be delivered in the short term at a system wide level


Relatively low Potential Productivity Opportunity in the Model Hospital and good feedback from NHSI

during Operational Productivity visit

Project Management Office(PMO) capacity / resources


CIP PMO heavily supported by CFT.

Fortnightly CIP meetings with Divisions, led by COO

Proposed Risk

Risk that the Trust does not identify and then deliver recurrent savings to

enable it to achieve its financial plan and make best use of its resources.

Effective, Responsive & Well -Led


Provider Board financial reporting schedules NHSI Finance reports


NHSI - Monthly reporting all organisations

Operational Plans each organisation


System wide Savings Plans to meet the "system control total" Provider Board Finance reports - including system wide savings plan / CIP delivery reports

Cost Improvement Plan (CIP) - Project Management Office ( PMO) established in each

organisation

Performance against system wide "Control Totals"


Date Risk reviewed

Rationale: Likelihood has been scored at 4 as will probably

happen, consequence has been scored at 3 as moderate

impact. Non-delivery of savings alone may not result in our

financial position being off plan but would contribute. TREAT


resources"


4.2 Sub Aim

Increase funds available for front line care by reducing costs across the

health system

Safety Culture

Strong Governance

Tackling Delay

CQC Domain

Links to SOF

A& E Delivery Board

Planned Care Board

Provider Board

0

0.5

1

A0

20

40



FC CFO


Initial 4 4 16

Current 3 4 12

Appetite 2 4 8

Approach

Rec'd/ RAG


Likelihood 3

Consequence 4

Risk rating 12


As at September IPR RTT = 80.9% A & E 83.4%,Cancer - Quarterly Standards met

Critical Care occupancy levels 99% ( 124% L3 and 65%L2)

Diagnostic performance 90%

CQC report received regarding 29a warning notice improvements notes

Outpatient Transformation Work is not yet impacting

RTT recovery outsourcing plans are not delivering required volumes


RTT Recovery Plans at specialty level

Cancer Recovery Programme

Critical Care Discharge Improvement Plan

Diagnostic Recovery Plan

SAFER work stream - to expedite discharges

Creating additional community bed capacity & packages of care

Exercise to test Winter Plans

OPD Transformation project is being refreshed to deliver clear KPI's


CIP performance reports

Gaps in assurance

RTT performance

Cancer performance

Critical Care occupancy levels

Diagnostic performance

Winter planning arrangements


QIDB reports

RTT Delivery Group

Transformation Team Resource

Cost Improvement Plan (CIP) Programme Management Office & programme resource



Links to SOF

Effective, Responsive & Well-Led


A& E Delivery Board

Planned Care Board


happen, consequence has been scored at 3 as moderate

impact. Non-delivery of savings alone may not result in our

financial position being off plan but would contribute.

Date Risk reviewed

Executive Lead

CQC Domain

Proposed Risk

Risk that the Trust does not increase quality, reduce cost for the Trust and the

system, and offer best value by delivering transformational schemes within the

health economy.

Strong Governance

Tackling Delay


Quality Improvement Plan

TREAT

Finance Committee reports


resources"


4.3 Sub Aim

Transform services to increase quality and reduce inefficiency and waste

Safety Culture

0

0.5

1

A0

20

40



FC CFO


Initial 4 4 16

Current 4 4 16

Appetite 2 4 8

Approach

Rec'd/ RAG


Likelihood 3

Consequence 4

Risk rating 12


Developments at both the Trust and system level not yet confirmed.


Gaps in assurance

Absence of TMG sign off for annual CITS RCHT Programme Plan


Lack of RCHT Digital Strategy

Ineffective communication of National digital requirements e.g. NHS Standard Contract 2017/19

- Service Conditions - NHS Mail Relay issue / SI

Lack of RCHT Executive oversight and prioritisation of new digital initiatives / 'innovations'

Absence of RCHT TMG sign off for annual CITS Programme Plan

Lack of RCHT Chief Clinical Information Officer (CCIO)

Lack of regular engagement with CDs and Clinical Divisions, Nurses and Therapists


Strategy in development for completion by 30 September 2018

More effective connectivity to Annual Plan and contract requirements

New initiatives to be discussed at E Health Programme Board before agreement at TMG

Identify how TMG will sign off annual CITS Programme as part of Annual Plan

Interviewing for CCIO on 1 August 2018

Operational

E Health Programme Board & Programme resources E Health Programme Board reports

Patient Survey results

Friends and Family Test (FFT) FFT results

Patient Survey

PROMs results Patient Reported Outcomes (PROMs)

Strong Governance

Tackling Delay

Digital Transformation Board Reports

Staff Survey Staff survey results

Digital Transformation Board & Programme resources

Links to SOF


happen, consequence has been scored at 4 as major as

nNo decision on emergency capital bid as at 12 Oct.

£1.5m+ pressure on Mortuary works as well as £0.5m on

MRI contingency and £1m on St Michael's Hospital. Partly

offset by underspends on Cath Lab and E Notes projects.

Risks also remain on medical capital equipment and fire

safety. Risk relates to the breach of the Capital Resource

Limit.

Effective, Responsive & Well-Led Use of

Resources Framework


E health Programme Board

Digital Transformation Board

TREAT

Date Risk reviewed

Executive Lead


resources"


4.4 Sub Aim

Ensure investments in technology and facilities improve experience for

staff and outcomes for patients

Safety Culture


Risk that the Trust is not able to access or prioritise capital resources to

enable it to ensure that service continuity is maintained, statutory

regulations are adhered to and services are improved through the use of

technology.

Proposed Risk

CQC Domain

0

0.5

1

A0

20

40


summary report 1 novembeer 2018 agenda nu mber: 14 title

Documents