Board meeting date:

5th February 2014 Agenda Item number:10.7

Enclosure:9

Report Title: Trust Wide Risk Register

Accountable Director: Wendy Pugh

Author (name & title): Neil Tong (NHSLA Facilitator)

Purpose of the report: To provide the Trust Board information on the Red Risks held on the “Trust Wide Risk Register”, in line with the Trust’s Risk Management Strategy. To update the Trust Board on any changes in relation to those risks held on the Trust Wide Risk Register and to provide the Trust Board with information on any risks being either escalated or de-escalated to/from the Trust Wide Risk Register.

Action required from the Board

Decision / Approval

Gain assurance

Discussion

Information

What other Trust Committee or Group has considered the key elements of this report?

Committee: Governance and Quality Committee

Date reviewed: 15th January 2014

Key points or recommendations from Committee:

The following risks have been reviewed by Governance and Quality Committee this month: • FINAN 1 • HR 002 • OPS 013 • Risk 178 The remaining risks (FT 14, STRAT 1 and STRAT 18, PERF09) have been reviewed by their appropriate Director or a nominated deputy. It is proposed that 2 risks are escalated to the Trust Wide Risk Register this month. The first of these is a new risk identified by the head of Estates and is a result of the departure of the Project Officer from the Estates Team and the resultant impact this will have on the capacity within the Team. The second of these has been escalated from the performance

and informatics department’s, departmental risk register and is in relation to the Trust’s assurance on data quality.

Strategic Objective(s) to which this paper relates:

High quality services

Inclusive partnerships

Leadership culture

Responsible workforce

Supporting strategies

Effective/efficient resources

What impact or implications does this report have on any of the following:

Please give brief details:

Quality & standards (inc. CQC/NHSLA) NHSLA:

• Standard 1.3 – High Level Risk Committees

• Standard 1.4 – Risk Register CQC Outcome 16 – Assessing and monitoring the quality of service provision.

Patient safety & experience Yes – Through the implementation of actions around many of the risks contained within the Trust Wide Risk Register.

Financial (income, expenditure & CIP) Yes – Risk FINAN 1 is specifically relates to the long term outlook in relation to CIP. Other risks STRAT 1, STRAT 18 and HR 002 have impacts upon the Trusts income streams.

Performance Yes – Some risks pertain to the Trusts performance against key internal targets and the associated negative impacts in failing to meet these.

Workforce & Leadership Yes – some risks pertain to issues around service redesign and may therefore have an impact upon

Equality & Diversity No – None of the risks appear to have significant impacts in relation to equality and diversity and any associated legislation.

Sustainability Yes – Strategic Risks such as STRAT 1 and STRAT 18 are associated with the sustainability of the organisation due to external influences, whilst risk FINAN 1 relates to its financial sustainability.

Risk Register/Board Assurance Framework Yes – NHSLA standards 1.3 and standard 1.4 (high Level Risk Committees and Risk Registers).

Patient & Public Involvement No – None of the risks pertain to patient and public involvement, however some of the risks contained within the Trust Wide Risk Register have been reviewed by the Trusts Experts by Experience via the Trusts Governance and Quality Committee.

Title Trust Wide Risk Register

Introduction

It is the purpose of this report to provide the Trust Board with the newly updated Trust Wide Risk Register. A number of these risks have been agreed and reviewed by the Trust’s Governance and Quality Committee these were risks:

• FINAN 1

• HR 002

• OPS 013

• Risk 178

In addition all risks are reviewed by their appropriate Director (or nominated deputy) and the report provides the Trust Board information on:

• Those risks which are being de-escalated from the Trust Wide Risk Register

• Any new risks being added/escalated to the Trust Wide Risk Register

• Updates to risks held on the Trust Wide Risk Register

Summary of key points, issues and risks

There are currently 8 risks held on Dudley and Walsall Mental Health Partnership NHS Trust’s, Trust Wide Risk Register. In line with the Trust’s Risk Management Strategy this report is an amalgamation of all the Red Risks across the organisation.

It is proposed that 2 risks should be added to the Trust Wide Risk Register this month:

Risk 178 – Which is a result of the departure of the Project Officer from the Estates Team and the subsequent impact this will have on the capacity within the Team. PERF09 – In relation to the Trust’s ability to maintain data quality due to a number of factors. This risk has been escalated from the Performance and Informatics Risk Register

Further detail (if required)

Tables 1.1 and 1.2 outline the sources of the risks held on the Trust Wide Risk Register and additional further details (including their impacts on Quality/Operational issues (where appropriate).

The full details of these risks are outlined in appendix 1 of this report.

Table 1.1

Source of risk (How the risk has been identified)

Number of risks on the TWRR

Strategically Identified 2

Departmental Priorities/Pressures 2

Feedback from stakeholders/partner agencies 1

Committee Actions/Options Appraisals 1

FT Project Risks 1

Finance Projections/Data 1

Table 1.2

Risk ID

Risk Description

Notes

Status of risk

FINAN 1 Inability to meet CIP targets and the impact on the viability of the Trust. Issues Include: * Costed service plans constantly in development * Lack of clarity around commissioner investment plans and resulting CIP requirement from existing baselines * Reduction in investment by Local Authorities * Efficiency of 4 percent has been experienced for a number of years and will be experienced going forward

Comments A thorough quality impact assessment against each CIP is currently being undertaken.

Any high risk quality issues highlighted will be escalated to the Executive Team for discussion outside of the Governance and Quality Committee

Further work is being undertaken to further integrate the ST and CIP PMO functions.

Update Risk reviewed minor amendments made to the wording of the risk. Additional controls and further action reviewed and agreed.

=

FT 14 Inability to re-activate FT application - Either due to: * Unsuccessful CQC assessment/non compliance * Local/Trust issues * Further unforeseen changes to the Monitor assessment process

Update Risk reviewed by Director of People and Corporate Development. Further actions and existing controls have been updated along with the wording of the risk to reflect the Trusts upcoming CQC assessment

=

HR 002 Reduction in Local Authority Funding for Mental Health Social Care Workforce, which may impact on service delivery

Comments All information is discussed at the Partnership Operational Group and any actions required are then put in place. The Local Authority is training more AMHPs for the future so the duties will be wider distributed Update Risk reviewed by Director of Operations and Nursing. The Trust are still awaiting Local Authority decision on exactly what posts are being put forward for VR.

Once the Trust has received this information, the impact of these changes can be measured.

Risk to remain a red risk to the organisation

=

OPS 013 A current lack of strategic direction in relation to records management leading to unacceptable practice in relation to record keeping within the organisation.

Update Risk reviewed by Governance Manager on behalf of Interim Director of Finance IT and Performance. Business case has been developed; a job description banded and is now out to advert.

=

STRAT 1 Delay in clarity of current health care reforms and associated implementation leads to uncertainty with commissioners (CCGs) that affects the Trusts ability to deliver its agenda primarily Service Transformation.

Update Risk reviewed. Risk to remain as a red risk to the organisation.

=

STRAT 18 Increasingly competitive environment for Health Care providers, potentially threatening existing and future business.

Comments Risk has been reviewed and updated by the Trusts Director of People and Corporate development. Update Risk has been reviewed. Risk to remain on the Trust Wide Risk Register

=

Risk ID

Risk Description

Notes

Status of risk

178 Departure of Project Officer from Estates team will reduce capabilities and capacity to deliver ST, Lifecycle and CIP programme for remainder of 2013-14 and jeopardise 2014-15 programme.

Comments Risk has been added by the Head of Estates. Risk has been reviewed by the Director of Operations and Nursing and the Trusts Governance and Quality Committee. It is expected that this risk will be relatively short lived due to the imminent appointment of a replacement Update Risk has been reviewed by Director of Operations and Nursing. Risk to be added to the Trust Wide Risk Register

▲

PERF09 The Trusts ability to maintain data quality due to a number of factors

Comments Risk has been escalated from Performance and Informatics Risk Register. Associated issues included * Lack of external assurance on data quality since the implementation of OASIS * Clinical and system processes not aligned * Capacity and cultural changes within operational teams regarding the prioritisations of data quality * Cultural challenges within the Performance and Informatics Teams * Lack of Effective interface between Informatics and Operational Teams * Increasing focus on the completeness and accuracy of the MHMDS by external bodies to form a view of the organisation in the context of an imminent CQC inspection. Update

Risk has been agreed by the Interim Director of Finance and IM&T

▲

Recommendation

It is recommended that the Trust Board approve the enclosed copy of the Trust Wide Risk Register and that the details included within this report outline the “Red Risks” to the organisation. In addition to this, agree with the recommendation that risk OPSASSO011 can now be closed.

Board action required

Trust Board are asked to discuss and approve the Trust Wide Risk Register.

Risk Register

R i s k

R isk D esc rip tion

S o u rce o f

R i s k

D a

te

P r i n c i p l e

O w ne r o f

R i s k

O t h e r

C o n t r i b u t o r s

In itia l S co re

S L

C o n t r o l s

C u r r e n t

S c o r e

S L

Fu rthe r A c tions R equ ired

R e s id u a l

S c o r e

S L

S o u rces o f

A ssu rance

D a

te o

f

Fu rthe r C o m m en ts

F INA N 1 Inab ility to m ee t C IP

ta rge ts and the

im pac t on the

v iab ility o f the T rus t.

Issues Inc lude :

* C os ted se rv ice

p lans cons tan tly in

d e v e lo p m e n t

* Lack o f c la rity

a round co m m iss ione r

investm en t p lans and

resu lting C IP

requ ire m en t fro m

ex is ting base lines

* R educ tion in

investm en t by Loca l

A u th o r itie s

* E ffic iency o f 4

pe rcen t has been

expe rienced fo r a

nu m be r o f yea rs and

w ill be expe rienced

go ing fo rw a rd

F ina nc e

P ro jec tions /

D a t a

28

/02

/20

11

D inah

M c lannahan 5 4

R ed

20 D e ta iled deve lop m en t o f cos t

im p rove m en t p rog ra m m e

A pp roach to C IP has been ag reed a t

F inance C o m m ittee

P M O B oa rd es tab lished Leve l o f C IP has been

co m m un ica ted to ope ra tiona l tea m s

fo llo w ing LTF M re fresh (Ju ly 2013 )

M anage m en t a rrange m en ts in p lace

fo r de live ry o f co rpo ra te cos t

s a v in gs

A rrange m en ts fo r m on ito ring

p rog ra m m e o f C IP no w in p lace

C IP ta rge ts be ing m e t th rough

ag reed d ises tab lish m en t

C on tinue to m anage locu m m ed ica l

cos ts as ag reed th rough F & a m p ;P

Q ua lity Im pac t A ssess m en t fo r a ll

2013 /14 and 2014 /15 sche m es a ll

upda ted

F inance tea m m e m be rs o f S e rv ice

T rans fo rm a tion w o rk g roups and

a lso dec is ion m ak ing P rog ra m m e

B oa rd

A c tive pa rtne r o f the M en ta l H ea lth

P rog ra m m e B oa rd m a in fo ru m fo r

co m m iss ione r lia ison .

S ens itiv ity ana lys is bu ilt in to

cu rren t p lans and fu rthe r deba te had

rega rd ing m on ito r assum p tions and

T rus t app roach to m itiga tion .

R e m ode lled e ffic iency p lan due to

changes in M on ito rs requ ire m en ts ,

ag reed by T rus t boa rd , F inance and

P e rfo rm ance co m m ittee and M E x T

S trong financ ia l pe rfo rm ance to

da te in yea r

R epo rting a rrange m en ts to boa rd

enhanced s ince A ugus t 2013 to

p rov ide m o re de ta il on sche m es as

w e ll as qua lity im pac t assessm en ts

M on ito ring o f bank , agency and

locu m s no w fo rm s pa rt o f finance

repo rt and d iscuss ion a t bo th F and

P and M E X T .

4 4

R ed

16 W o rk requ ired to ensu re P O D s and

repo rting fra m e w o rk is linked

e ffec tive ly in to co m p le ted Q ua lity

Im pac t A ssess m en ts (O ngo ing ).

R ev ie w o f repo rt fro m rev ised

P O D s and repo rting fra m e w o rk

a c c o rd in g ly

5 1

G reen

5 V a rious F inance

and P e rfo rm ance

repo rts inc lud ing :

R epo rts to B oa rd

R epo rts to F & P

C o m m i tt e e

inc lud ing

ind iv idua l ac tion

p lans on p ressure

a rea s .

R epo rts to M EXT

R ev ie w s by

ex te rna l

a s s es s o r s

inc lud ing S H A ,

H D D and M on ito r

In te rna l aud it

repo rts a round

C IP g iv ing

fu rthe r assurance

24

/01

/20

14

R Isk rev ie w ed and

upda ted by A c ting

D irec to r o f IM & T . F u rthe r

ac tions and ex is ting

con tro ls have been

upda ted .

Risk Register

R i s k

R isk D esc rip tion

S o u rce o f

R i s k

D a

te

P r i n c i p l e

O w ne r o f

R i s k

O t h e r

C o n t r i b u t o r s

In itia l S co re

S L

C o n t r o l s

C u r r e n t

S c o r e

S L

Fu rthe r A c tions R equ ired

R e s id u a l

S c o r e

S L

S o u rces o f

A ssu rance

D a

te o

f

Fu rthe r C o m m en ts

F T 14 Inab ility to re -ac tiva te

F T app lica tion - E ithe r

due to :

* U nsuccessfu l CQ C

a s s es s m e n t/no n

co m p lianc e

* Loca l/T rus t issues

* F u rthe r un fo reseen

changes to the

M on ito r assessm en t

p roc ess

F T P ro jec t

R i s k s

09

/05

/20

13

M a rsha

In g ra m

Trust Directors 4 4

R ed

16 E xpe rienced FT P ro jec t M anage r

F TPB and T rus t B oa rd ove rs igh t o f

in te rna l p rocesses

R obus t links w ith M on ito r and NHS

T DA

D e ta iled rev ie w o f Q ua lity and

G ove rnance C o m m ittee has been

c o m p le te d .

R obus t pe rfo rm ance m anage m en t

reg im e

B oa rd s ign -o ff o f de ta iled ac tion

p lans to add ress M on ito r feedback

F T P rog ra m m e B oa rd is in p lace .

R obus t p lan to rec ru it to F inance

D irec to r pos t s igned o ff by B oa rd .

R egu la r p rog ress d iscuss ions be ing

he ld w ith M on ito r assessm en t tea m .

C on firm a tion o f T im ing o f C Q C p ilo t

a s s e s s m e n t.

T D A independen t rev ie w o f

reac tiva tion requ ire m en ts co m p le ted

D a ta qua lity im p rove m en t p lan no w

in p lace

Q G A F se lf assessm en t sco re 3 .5 o r

below

C Q C A ssess m en t p ro jec t g roup

es tab lised w ith regu la r repo rts to

M E x T and G ove rnance and Q ua lity

C o m m i tt e e

4 4

R ed

16 S us ta ined im p rove m en t in D a ta

Q ua lity P e rfo rm ance (ongo ing )

C on tinued unde rs tand ing o f the

C Q C s assessm en t m e thods and

ou r o w n in te lligence ga the ring .

4 1

G reen

4 F TPB repo rts an

M inu tes

R egu la r repo rts

to M E x T ,

G ove rnance and

Q u a li t y

C o m m ittee and

T rus t B oa rd

24

/01

/20

14

R isk upda ted by D irec to r

o f P eop le and C o rpo ra te

D e v e lo p m e n t.

R isk w o rd ing a m ended to

re flec t T rus ts fo rthco m ing

C Q C assessm en t.

Risk Register

R i s k

R isk D esc rip tion

S o u rce o f

R i s k

D a

te

P r i n c i p l e

O w ne r o f

R i s k

O t h e r

C o n t r i b u t o r s

In itia l S co re

S L

C o n t r o l s

C u r r e n t

S c o r e

S L

Fu rthe r A c tions R equ ired

R e s id u a l

S c o r e

S L

S o u rces o f

A ssu rance

D a

te o

f

Fu rthe r C o m m en ts

H R 002 R educ tion in Loca l

A u tho rity F unding fo r

M en ta l H ea lth S oc ia l

C a re W o rk fo rce ,

w h ich m ay im pac t on

se rv ice de live ry

F e e d b ack

F r o m

S takeho lde rs /

P

30

/05

/20

12

W e n d y

P ugh 4 4

R ed

16 S ec tion 75 ag ree m en ts p rov ide

fo rm a l p la tfo rm as the bas is fo r

any fu rthe r nego tia tions in fund ing

and resou rce changes

V ia res truc tu re , sen io r pos t w h ich

w ill no w focus on pa rtne rsh ip issues

w ill enab le g rea te r c la rity and e ffo rt

in th is a rea .

Jo in t app roach ag reed w ith W a lsa ll

M B C rega rd ing im p le m en ta tion o f

fund ing reduc tions .

R isk A ssess m en ts on cu rren t loss

o f pos ts has been co m p le ted

R egu la r d iscuss ions be ing he ld a t

P a rtne rsh ip O pe ra tions G roup .

A dd itiona l sho rt te rm capac ity has

been co m m iss ioned

S ec tion 75 ag ree m en ts have been

s igned

4 4

R ed

16 D iscuss ions ongo ing a t P O G

(M on th ly )

T o have in fo rm a tion and to

unde rs tand so m e fu rthe r p roposed

reduc tions in fund ing (O c tobe r

P a rtne rsh ip B oa rd )

4 1

G reen

4 R epo rts to M EXT

U pda tes to B oa rd 0

2 /0

1 /2

01

4

R isk rev ie w ed by D irec to r

o f O pe ra tions and

N u rs ing . T he T rus t a re

s till a w a iting Loca l

A u tho rity dec is ion on

exactly w ha t pos ts a re

be ing pu t fo rw a rd fo r V R .

O nce the T rus t has

rec ieved th is in fo rm a tion

the im pac t o f these

changes can be

m eas u red .

O P S 013 A cu rren t lack o f

s tra teg ic d irec tion in

re la tion to reco rds

m anage m en t lead ing

to unacceptab le

p rac tice in re la tion to

reco rd keep ing w ith in

the o rgan isa tion .

C o m m i tt e e

A c tions /

O p tions A p

01

/04

/20

11

D inah

M c lannahan 4 4

R ed

16 A n op tions app ra isa l has been

co m p le ted in re la tion to the fu tu re

d irec tion o f reco rds m anage m en t

w ith in the o rgan isa tion .

T he o rgan isa tion is to e m p loy an

In te rim R eco rds M anage r to add ress

the issues rega rd ing reco rds

m anage m en t w ith in the o rgan isa tion .

W e have used the se rv ices o f a

consu ltan t to ensu re the

o rgan isa tion has s tra teg ic op tions

as a w ay fo rw a rd . T h is w ill be

w o rked up ove r the nex t 6 m on ths .

Loca l aud its a re in p lace re the

qua lity o f c lin ica l reco rds and these

a re fed th rough to a va rie ty o f

c o m m i tt e e s

A nu m be r o f reco rds in a rch ive

have been lifted fro m F M C to

R eca ll w ith se rv ice be ing o ffe red a t

a be tte r ra te .

T ra in ing sess ions have p rov ided to

s ta ff w ho m ay be requ ired to

reques t reco rds fro m o f s ite

s to rage .

O ff s ite reco rds in a rch ive have

been trans fe rred fro m F M C to

R ec a ll

4 4

R ed

16 K ey dec is ions to be m ade

rega rd ing :

o In teg ra tion o f m ed ica l and nu rs ing

n o tes

o R eco rds T racking P rocesses

o A ccoun tab le co m m ittees

o S tanda rd ised fo rm a ts

o Issues a round a rch iv ing p rac tices

(S o m e o f s ite reco rds in a rch ive

have been T rans fe rred fro m F M C to

R e c a ll)

o T ra in ing (T ra in ing sess ions have

been p rov ided fo r s ta ff w ho m ay be

requ ired to

requ ire reco rds he ld o ff s ite )

(D ec is ions to be m ade based upon

s tra tegy co m p le tion (due June

2013 )

Job is cu rren tly ou t to adve rt and

has been banded as a band 7 .

R ec ru itm en t expected by Janua ry

2014

D iscuss ions cu rren tly ongo ing w ith

R eca ll. T he T rus t is cu rren tly

exp lo ring scann ing so lu tions and the

res tric tions o f no te m ove m en t.

P resen ta tion by R eca ll a t the N ex t

IG and R M C o m m ittee

4 1

G reen

4 R epo rts to key

co m m ittees such

as M e X T ou tlin ing

p rog ress

01

/01

/20

14

R isk rev ie w ed by

G ove rnance M anage r on

beha lf o f D irec to r o f

In te rim D irec to r o f

F inance , IT and

P e rfo rm ance . B us iness

case has been deve loped ,

a job descrip tion banded

and is no w ou t to adve rt.

Risk Register

R i s k

R isk D esc rip tion

S o u rce o f

R i s k

D a

te

P r i n c i p l e

O w ne r o f

R i s k

O t h e r

C o n t r i b u t o r s

In itia l S co re

S L

C o n t r o l s

C u r r e n t

S c o r e

S L

Fu rthe r A c tions R equ ired

R e s id u a l

S c o r e

S L

S o u rces o f

A ssu rance

D a

te o

f

Fu rthe r C o m m en ts

A dd itiona l con tro ls have been

im p le m en ted to res tric t the m isuse

o f o ff s ite s to rage and to ensu re

tha t hea lth reco rds a re des troyed in

line w ith In fo rm a tion G ove rnance

bes t p rac tice .

T rus t is to unde rtake a re fresh in

re la tion to th is issue and a re to look

a t in te rna l so lu tions to m itiga te any

a c t io ns .

In te rna l aud it to be ing w o rk on A ud it

o f S ys te m s and con tro ls a round

hea lthca re reco rds m anage m en t in

qua rte r 3 o f 2013 /14 . T h is w ill he lp

in fo rm w he the r the cu rrne t s truc tu re

suppo rts the requ ired gove rnance o r

w he the r fu rthe r changes a re

requ ired .

S T RA T 1 U nce rta in ty in

co m m iss ione rs in ten t

as a resu lt o f hea lth

ca re re fo rm s and

the ir associa ted

im p le m en ta tion m ay

a ffec t the T rus ts

ab ility to de live r its

agenda , p rim a rily

S e r v ic e

T rans fo rm a t io n .

S tr a te g ic a l ly

Id e n t i fie d

01

/04

/20

11

M a rk

W e a v e r

Kate Gingell

Trust Directors

James Parker

Jacky

O'sullivan

4 4

R ed

16 S ys te m p lans ag reed by T rus t,

C lus te r and P C T s .

M en ta l H ea lth P rog ra m m e B oa rd is

e s ta b lis hed .

C o m m iss ione r se rv ice redes ign and

capac ity p lann ing g roup in p lace .

R es idua l re la tionsh ips w ith ex is ting

P C T /C lus te r s ta ff.

In fo rm a l m ee tings to c la rify issues

and m anage ou tco m es be ing

es tab lished and re la tionsh ip

m anage m en t

E ngage m en t even ts he ld in bo th

bo roughs A ug 11 w ith G P and

co m m iss ione r a ttendance

T rus t a ttends co m m iss ione r C Q R

m ee ting (m e m be rsh ip expanded )

Y ea r 2 p lans p resen ted to C CG s

B oa rd to B oa rd m ee tings w ith B o th

C C G boa rds .

4 4

R ed

16 N eed to F u rthe r D eve lop

re la tionsh ips w ith G P s and C CG s to

take th rough ou r jou rney o f ST

(O ngo ing m on th ly m ee tings ) E nsu re lock in o f co m m iss ione rs ,

C C G s and C lus te rs to sys te m

p lans (O ngo ing )

4 2

A m be r

8 S e r v ic e

T rans fo rm a tion

Im p lim en ta tion

G roup

M en ta l H ea lth

P rog ra m m e

B oa rd

T rus t B oa rd

S HA F T

read iness

a s s e s s m e n t

p r o c es s .

S tra teg ic

P a r tne rs .

F oundation T rus t

A s s e s s m e n t

p roc ess

02

/01

/20

14

N o changes to risk . R isk

to re m a in on the T rus t

W ide R isk R eg is te r as a

"red risk ".

Risk Register

R i s k

R isk D esc rip tion

S o u rce o f

R i s k

D a

te

P r i n c i p l e

O w ne r o f

R i s k

O t h e r

C o n t r i b u t o r s

In itia l S co re

S L

C o n t r o l s

C u r r e n t

S c o r e

S L

Fu rthe r A c tions R equ ired

R e s id u a l

S c o r e

S L

S o u rces o f

A ssu rance

D a

te o

f

Fu rthe r C o m m en ts

STRAT

18

In c r e as in g ly

c o m p e t i t iv e

env iron m en t fo r

H ea lth C a re

p rov ide rs , po ten tia lly

th rea ten ing ex is ting

and fu tu re bus iness.

S tr a te g ic a l ly

Id e n t i fie d

01

/04

/20

11

G a r y

G raha m

Marsha Ingram 4 4

R ed

16 M a rke t ana lys is th rough F oundation

T rus t IB P .

C E O and C ha ir focusing on

deve lop m en t o f re la tionsh ips w ith

ne w co m m iss ion ing bod ies .

O ngo ing im p le m en ta tion o f S e rv ice

L ine R epo rting i.e . p ro fit and loss

by se rv ice line .

S ta rted to cons ide r a t T rus t B oa rd

the po ten tia l a reas o f g ro w th fo r the

T rus t.

R isk is re la ted to co m m iss ione r/G P

in ten tions go ing fo rw a rd re se rv ice

co m pe tition o r look ing to p lu ra lity o f

p r o v id e r s .

T rus t B oa rd D iscuss ions

B us iness O ppo rtun ities tea m

deve loped by C E

E s tab lish m en t o f M a jo r P ro jec ts

B oa rd to ove rsee s tra teg ic

d e v e lo p m e n ts

B o th C CG s rep resen ted on S hado w

C ounc il o f G ove rno rs

M a rke t in te lligence repo rting to T rus t

B oa rd

T rus t has rec ru ited a B id S uppo rt

M anage r to suppo rt the iden tifica tion

o f ne w B us iness O ppo rtun ities .

T he T rus t is no w p roac tive ly

deve lop ing bus iness cases w ith

c o m iss io n e rs

F unding has been secu red fo r

co m m e rc ia l a w a reness tra in ing .

R ec ru itm en t o f resou rces to B O T -

B id M anage r w ho has se t up regu la r

feeds on fo rthco m ing tende rs .

B oa rd dec is ion to inc rease focus on

bus iness deve lop m en t - se t up o f

'G ro w th P M O '

B us iness deve lop m en t P M O m ode l

ag reed and im p le m en ted .

T rus t boa rd have ag reed tha t g ro w th

is a s tra teg ic p rio rity fo r the F u tu re

4 4

R ed

16 F u lly e m bed bus iness deve lop m en t

P M O m ode l (Ju ly 2014 )

F u lly im p le m en t se rv ice line

repo rting

C on tinue to cap ita lise on ex is ting

m echan is m s to in fluence

co m m iss ione rs (M en ta l H ea lth

P rog ra m m e B oa rd ) to m a in ta in

s tab ility in the hea lth econo m y

(ongo ing - R ev ie w ed m on th ly ).

4 3

A m be r

12 F T P ro jec t B oa rd

In teg ra ted

B us iness P lan

M en ta l H ea lth

P rog ra m m e

B oa rd

B us iness

D e v e lo p m e n t

P M O repo rt to

T rus t B oa rd

24

/01

/20

14

R isk rev ie w ed by D irec to r

o f P eop le and C o rpo ra te

D e v e lo p m e n t.

R eco m m enda tion tha t the

res idua l sco re o f th is risk

is inc reased .

Risk Register

R i s k

R isk D esc rip tion

S o u rce o f

R i s k

D a

te

P r i n c i p l e

O w ne r o f

R i s k

O t h e r

C o n t r i b u t o r s

In itia l S co re

S L

C o n t r o l s

C u r r e n t

S c o r e

S L

Fu rthe r A c tions R equ ired

R e s id u a l

S c o r e

S L

S o u rces o f

A ssu rance

D a

te o

f

Fu rthe r C o m m en ts

178 D epa rtu re o f P ro jec t

O ffice r fro m E s ta tes

tea m w ill reduce

capab ilities and

capac ity to de live r

S T , L ifecycle and

C IP p rog ra m m e fo r

re m a inde r o f 2013 -14

and jeopa rd ise

2014 -15 p rog ra m m e .

D e p a rtm e n ta l

P rio rities /

P res

01

/12

/20

13

W e n d y

P ugh

Richard Best 5 3

R ed

15 F o rm a l handove r 30 th D ece m be r.

N o te handove r is a cu rren t s ta tus

o f ex is ting p rog ra m m e o f w o rks and

those cu rren tly in p ipe line .

A gency in te rv ie w ed 2nd & 3 rd Jan

2014

5 3

R ed

15 F o rm a l rev ie w o f band ing fo r pos t

unde rw ay .

D ue to go in fron t o f rev ie w pane l

ea rly 2014 .

A t p resen t risk no t m itiga ted un til

resou rce in p lace - e ithe r th rough

agenc ies (in te rim m easu re ) o r

d irec ly e m p loyed

5 1

G reen

5 R ec ru itm e n t

p rocess in itia ted

24

/12

/20

13

N e w risk added .

R eco m m enda tion fo r risk

to be added to the T rus t

W ide R isk R eg is te r and

C ons ide red as a R ed

R i s k .

R isk w ill be fu rthe r

m itiga ted fro m the 14 th

Janua ry th rough the

e m p loy m en t o f an

agency w o rke r on an

in te rim agency ag ree m en t

fro m the 14 th Janua ry

un ti l the 31s t M a rch

P E R F 0 9 M a in ta in ing D a ta

Q ua lity Issues ;

* Lack o f ex te rna l

assurance on da ta

qua lity s ince the

im p le m en ta tion o f

O A S IS

* C lin ica l and sys te m

p rocesses no t a ligned

* C apac ity and

cu ltu ra l changes

w ith in ope ra tiona l

tea m s rega rd ing the

p rio ritisa tions o f da ta

q u a lity

* C u ltu ra l cha llenges

w ith in the

P e rfo rm ance and

In fo rm a tics T ea m s

* Lack o f E ffec tive

in te rface be tw een

In fo rm a tics and

O pe ra tiona l T ea m s

* Inc reas ing focus on

the co m p le teness and

accuracy o f the

M H M DS by ex te rna l

bod ies to fo rm a v ie w

o f the o rgan isa tion in

the con tex t o f an

im m inen t CQ C

ins p ec t io n .

D e p a rtm e n ta l

P rio rities /

P res

13

/07

/20

12

D inah

M c lannahan

Chris

Reynolds

2 2

G reen

4 L ive da ta qua lity im p rve m en t p lan

in p lace

In te rna l aud its p rog ra m m ed fo r Q 4

on D a ta Q ua lity Im p rove m en t

P rog ra m

D Q cu rren tly sc ru tin ized a t CA R M

A dd itiona l resou rce in p lace w ith in

In fo rm a tics to im p rove D a ta Q ua lity

R egu la r co m m un ica tion be tw een

P e rfo rm ance and In fo rm a tics tea m s

and O pe ra tiona l T ea m s

T ra in ing p rog ra m o f O as is and

C lin ica l P rocesses is cu rren tly in

p lace

A live ac tion p lan dea ling w ith the

co m p le teness o f the M H M DS

s ub m is s io n

S igned o ff m e tric spec ifica tion

docu m en t in p lace fo r a ll K ey

P e rfo rm ance Ind ica to rs

4 4

R ed

16 R o llou t o f E O A S IS to co m m un ity

se rv ices . D ependen t on

func tiona lity ava ilab le in p roduc t

(Ju ly 2014 )

R o ll ou t O A S IS to inpa tien ts to

im p rove co m p le teness o f da ta and

reduce risk o f dup lica tion o r e rro r

(M a rch 2014 ) R e es tab lish an e ffec tive c lin ica l

p rocess g roup tha t w ill he lp to

ensu re sys te m and c lin ica l p rocess

a lign m en t (ope ra tion o f the g roup is

c ritica l) (M a rch 2014 )

E nsu re sys te m a tic p rog ra m o f

oas is tra in ing and suppo rt to ensu re

c lin ica l p rocesses ag reed a re then

re flec ted in oas is .

E nsu re ro ling p rog ra m o f da ta

qua lity im p rove m en t (O ngo ing )

E nsu re regu la r in te rna l aud it/rev ie w

(ongo ing )

E nsu re regu la r jo in t in fo rm a tics and

ope ra tions m ee ting to d iscuss

kno w n issues (ongo ing ) C lose m anage m en t o f the

in fo rm a tics func tion to ensu re tha t

ro les and responsib ilities a re

re flec tive o f the needs o f the

o rgan isa tion

E nsu re co m p le tion to tim escale o f

ac tion p lan in re la tion to M H M DS

4 2

A m be r

8 In te rna l A ud its

D a ta qua lity

repo rts to CA R M

24

/01

/20

14

R isk escala ted fro m

P e rfo rm ance and

In fo rm a tics R isk R eg is te r

to T rus t W ide R isk

R e g is te r .

Risk Register

R i s k

R isk D esc rip tion

S o u rce o f

R i s k

D a

te

P r i n c i p l e

O w ne r o f

R i s k

O t h e r

C o n t r i b u t o r s

In itia l S co re

S L

C o n t r o l s

C u r r e n t

S c o r e

S L

Fu rthe r A c tions R equ ired

R e s id u a l

S c o r e

S L

S o u rces o f

A ssu rance

D a

te o

f

Fu rthe r C o m m en ts

(A p ril 2014 )