Trust Board papers November 2012 - Barking Havering and ...
Trust Board papers November 2012 - Barking Havering and ...
Trust Board papers November 2012 - Barking Havering and ...
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PRINCIPAL RISK<br />
What could prevent the objective being<br />
achieved<br />
Risk no, Date on Risk Register<br />
& Risk Scoring:<br />
KEY EXISTING CONTROLS<br />
What controls/systems are in<br />
place to assist in securing delivery<br />
of objective <strong>and</strong> managing<br />
principle risks?<br />
CQC REF:<br />
RESIDUAL RISK<br />
ASSURANCES ON<br />
CONTROLS & IMPACT<br />
Where we gain evidence<br />
that our controls/systems, on<br />
which we are placing<br />
reliance, are effective? The<br />
impact following assurances.<br />
PROGRESS AGAINST<br />
RISKS/ ACTION<br />
PLAN UPDATE<br />
What Actions are undertaken to<br />
mitigate the actual risks?<br />
GAPS IN ASSURANCE<br />
Where we are failing to gain<br />
evidence that our controls /<br />
systems, on which we place<br />
reliance, are effective<br />
GAPS IN<br />
CONTROL<br />
Where are we<br />
failing to put<br />
controls / systems<br />
in place? Where are<br />
we failing in making<br />
them effective?<br />
LEAD<br />
Principal Objective: Deliver all local / national st<strong>and</strong>ards <strong>and</strong> targets including comply with CQC, RMS & HSE regulations - NHSLA<br />
Risks 298: Failure to achieve<br />
Level 2 Accreditation of Risk<br />
Management St<strong>and</strong>ards<br />
(RMS) which will achieve<br />
increased patient safety<br />
systems recognised by NHS<br />
Litigation Authority <strong>and</strong><br />
reduction in annual premium,<br />
causing increased scrutiny<br />
from external regulators.<br />
Date on Register: 17.08.2011<br />
Rating Scoring: Impact :4 x<br />
Likelihood:4 = 20<br />
Area: <strong>Trust</strong><br />
Impact on:<br />
Patient: Increased patient safety<br />
Staff: Morale <strong>and</strong> pride in care<br />
provided.<br />
<strong>Trust</strong>: The <strong>Trust</strong> sustaining<br />
progressive quality improvement<br />
measures<br />
Up-to-date gap analysis,<br />
Medical Devices Committee,<br />
Medical Records keeping<br />
committee, RMS co-ordinating<br />
committee.<br />
16<br />
High Risk<br />
Frequent meeting with<br />
Risk Management<br />
Criterion Leads the<br />
feedback is filtered in the<br />
gap analysis report<br />
Risk Management<br />
Steering Group monitors<br />
the status<br />
This risk is cross<br />
referenced to the BHRUT<br />
CQC related<br />
development plan <strong>and</strong><br />
the references are G 40 -<br />
45<br />
Proposal to provide a<br />
businesses case for staff to<br />
support the RMS process, job<br />
descriptions are currently<br />
reviewed in light of potential<br />
posts<br />
Review in resourcing as part<br />
of the clinical governance<br />
overview was presented to<br />
TEC <strong>and</strong> <strong>Trust</strong> <strong>Board</strong>.<br />
Quality <strong>and</strong> Safety Committee<br />
approved resource plan in<br />
principle. An “ invest to save”<br />
business case being<br />
developed against the<br />
achievement of level 2 <strong>and</strong> 3<br />
RMS st<strong>and</strong>ards.<br />
Financial resourcing<br />
required<br />
Areas of high risk:<br />
Medical Devices<br />
Lead Trainer,<br />
Centralised<br />
training records,<br />
Release of staff<br />
for training,<br />
Medical record<br />
keeping<br />
(documentation)<br />
Collecting<br />
evidence of Risk<br />
Management<br />
St<strong>and</strong>ards<br />
Storage of data<br />
(electronic)<br />
Lyn Wilson/ Pam Strange Clinical Governance Director<br />
Details updated: 15.10.12<br />
No change<br />
BHRUT BAF 2nd Quarter <strong>2012</strong>: SB/PS<br />
10