Trust Board papers November 2012 - Barking Havering and ...

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