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

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CARE QUALITY COMMISSION: Regulations and Outcome Guide Regulation 17 Outcome 1: Respecting and involving people who use services Regulation 18 Outcome 2: Consent to care and treatment Regulation 9 Outcome 4: Care and welfare of people who use services Regulation 14 Outcome 5: Meeting nutritional needs Regulation 24 Outcome 6: Co-operating with other providers Regulation 11 Outcome 7: Safeguarding people who use services from abuse Regulation 12 Outcome 8: Cleanliness and infection control Regulation 13 Outcome 9: Management of medicines Regulation 15 Outcome 10: Safety and suitability of premises Regulation 16 Outcome 11: Safety, availability and suitability of equipment Regulation 21 Outcome 12: Requirements relating to workers Regulation 22 Outcome 13: Staffing Regulation 23 Outcome 14: Supporting workers Regulation 10 Outcome 16: Assessing and monitoring the quality of services Regulation 19 Outcome 17: Complaints Regulation 20 Outcome 21: Records BHRUT BAF 2nd Quarter 2012: SB/PS 19
EXECUTIVE SUMMARY TITLE: Risk Management Strategy and Policy BOARD/GROUP/COMMITTEE: Trust Board 1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and DATE: The attached Risk Management Strategy and Policy describes the Trusts expectations of how the management of risk at different levels within the organisation must be managed. This has been updated in line with national guidance and local developments and changes to systems and processes. The key changes to this document over the previous one include: Update to comply with the revised NHS Litigation Authority Risk Management Standards issued this year. The Roles and Responsibilities have been revised in line with leadership and responsibility changes. (P.6) Introduction of the NPSA recently revised risk grading matrix. (Appendix 1 P.33) Framework for Risk Management self assessment tool to support staff in the development and monitoring of risk management systems. (Appendix 3 P. 38) The routine systems for all staff remain essentially the same. □ TEC ……………... □ STRATEGY……….….……. □ FINANCE ……..……… □ AUDIT ………….……..…. x QUALITY & SAFETY …………..………….....…… □ WORKFORCE □ CHARITABLE FUNDS ………………………………...… □ TRUST BOARD ……………………………….…………. □ REMUNERATION ………………………………….…... □ OTHER …………………………..……. (please specify) Training on the document is provided at every Induction, Mandatory Training and Junior Doctor training. . 2. DECISION REQUIRED: CATEGORY: It is a requirement of the NHSLA Risk Management Standards that the Trust Board approve the attached Strategy and Policy NATIONAL TARGET x RMS x CQC REGISTRATION x HEALTH & SAFETY x ASSURANCE FRAMEWORK □ CQUIN/TARGET FROM COMMISSIONERS CORPORATE OBJECTIVE …………………………….... □ OTHER …………………….. (please specify) AUTHOR/PRESENTER: Dr Mike Gill DATE: 26.10.12 3. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST: 4. DELIVERABLES 5. KEY PERFORMANCE INDICATORS AGREED AT ______________________ MEETING OR REFERRED TO: __________________________ DATE: ____________________________ DATE: ____________________________ REVIEW DATE (if applicable) ___________________________
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TRUST BOARD MEETING Wednesday, 7 No
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2 Following Mr White’s concerns r
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4 forecast in terms of community be
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6 The Trust Board noted the Plan fo
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8 The Co-Chair of the Improving Pat
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TRUST BOARD MEETING Actions from Mi
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Agenda Item Action Deadline Date Da
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Question: Mr Skillman was pleased t
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CQC Trust-wide Action Plan Review a
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1.0 PURPOSE 1.1 Background This rep
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• Review the Senior Responsible O
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APPENDIX 1 ‐ CQC ACTION PLAN - EX
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RECORDS records management to ensur
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CQC Update Report 2012 Theme CQC Re
Page 29 and 30: CQC Update Report 2012 ASSESSING &
Page 31 and 32: CQC Update Report 2012 ASSESSING &
Page 33 and 34: CQC Update Report 2012 pathways thr
Page 35 and 36: CQC Update Report 2012 identified i
Page 37 and 38: CQC Update Report 2012 outlining th
Page 39 and 40: CQC Update Report 2012 improvements
Page 41 and 42: CQC Update Report 2012 aware of the
Page 43 and 44: CQC Update Report 2012 are now supe
Page 45 and 46: CQC Update Report 2012 autumn. RECO
Page 47 and 48: CQC Update Report 2012 of the pilot
Page 49 and 50: EXECUTIVE SUMMARY TITLE: Informatio
Page 51 and 52: INFORMATION GOVERNANCE STRATEGY 201
Page 53 and 54: Information is a vital asset in ter
Page 55 and 56: starters as well as being mandatory
Page 57 and 58: The standards are split into the ar
Page 59 and 60: 10a Reapproval of IG training progr
Page 61 and 62: 343 Directorate Anaesthetic: Risk:
Page 63 and 64: Table of Contents TRUST PRINCIPAL O
Page 65 and 66: BHRUT STRATEGIC OBJECTIVES WITH EAC
Page 67 and 68: DIRECTORATES RISKS REVIEW 12 10 8 6
Page 69 and 70: RISKS DETAILS PRINCIPAL RISK What c
Page 71 and 72: PRINCIPAL RISK What could prevent t
Page 77 and 78: RISK DESCRIPTORS OBJECTIVE SAFE, HI
Page 79: BOARD ASSURANCE FRAMEWORK ELEMENTS
Page 83 and 84: Contents Section Page 1 Introductio
Page 85 and 86: incorporate mitigation controls wit
Page 87 and 88: “Risk Register” “Risk Registe
Page 89 and 90: potential risks they may face in ac
Page 91 and 92: 4.1.1 Quality and Safety Committee
Page 93 and 94: • Financial risks: risks associat
Page 95 and 96: Proactive risk assessment enables t
Page 97 and 98: Trust’s risk matrix and will popu
Page 99 and 100: Risk Grading Staff Group Evidence R
Page 101 and 102: 4.8 RISK REGISTER The Risk Register
Page 103 and 104: 5.1 Consultation and Communication
Page 105 and 106: The Trust recognises the importance
Page 107 and 108: timescale with supporting evidence
Page 109 and 110: Checklist for the Review and Approv
Page 111 and 112: Equality Impact Assessment Tool To
Page 113 and 114: Plan for Dissemination of Procedura
Page 115 and 116: Consequence score (severity levels)
Page 117 and 118: Frequency How often might it/does i
Page 119 and 120: Appendix 3 Framework for Risk Manag
Page 121 and 122: Risk Register inventory they are ex
Page 123 and 124: 2. DECISION REQUIRED: CATEGORY: The
Page 125 and 126: • A review of data capture to ens
Page 127 and 128: Pilot Wards Division Discharges Per
Page 129 and 130: Workforce Appraisals - the actions
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Delayed transfers of care (DTOC) -
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EXECUTIVE SUMMARY TITLE: Emergency
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• Training competencies are being
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Appendix A: Trajectory for all type
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would welcome feedback from the Tru
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Maternity Services Monthly Performa
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4. Capping The maternity service is
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7. Obstetric Assessment Unit (OAU)
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10. Serious Incidents Reported Inci
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12. Maternity Dashboard The dashboa
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It should also be noted that the ta
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Priority Action Lead Monitoring Too
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Priority Action Lead Monitoring Too
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Contents Section No: Description Pa
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3. Complaints Activity 3.1 Total Co
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3.5 Themes General care issues and
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Corporate Non Clinical Category Num
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order to resolve concerns. Particul
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The findings of the review were tha
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SELF-CERTIFICATION RETURNS Organisa
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12 AA - Quality Improvement Strateg
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TFA Progress BHR University Hospita
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25 TFA - Final IBP /; LTFM Dec-12 H
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Effectiveness GOVERNANCE RISK RATIN
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Safety 4b MRSA Enter Are you below
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FINANCIAL RISK RATING BHR Universit
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CONTRACTUAL DATA BHR University Hos
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4 Single Sex Accommodation Breaches
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TITLE: EXECUTIVE SUMMARY BOARD/GROU
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causes/ Not specified' will be remo
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Staff In Post Starters & Leavers FT
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TURNOVER Actual Versus Target Annua
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FTE Lost due to Sickness Absence by
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The data on the previous page has b
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Indicator Target Apr-12 May-12 Jun-
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Starters *¹ 7.00 3.60 5.00 7.43 6.
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EXECUTIVE SUMMARY TITLE: COST IMPRO
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Month 6 CIP Performance Workstream
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Governance The Cost Improvement Pro
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1 REPORT TO: REPORT FROM: Trust Boa
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3 Preparations for winter planning
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5 Preparing the Payment by Results
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7 People with dementia to receive m
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9 Clinical Patient Management and H
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102/2012 Apologies Apologies were r
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Action Members were advised that ac
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Action 115/2012 Any Other Business
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EXECUTIVE SUMMARY TITLE: Finance Re
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1. EXECUTIVE SUMMARY Monthly I&E Ru
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Trust I&E summary by Division/Direc
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Income by POD In Month Year to date
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Devolved income Annual Budget Forec
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4. BALANCE SHEET Balance Sheet Curr
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6. Business Unit Summaries Attached
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