Stephen Wheeler, Non Executive Director Lynn Vaughan, Director of Human. 1 Non Clinical Risk Committee (NCRC)

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1 Report to: Public Trust Board Date of Meeting: 8 July 2009 Agenda item: 4.1 Title of Report: Status: Board Sponsor: Author: Appendices Non Clinical Risk Committee (NCRC) Report Information Stephen Wheeler, Non Executive Director Lynn Vaughan, Director of Human 1 Non Clinical Risk Committee (NCRC) Report 1. Purpose of Report (Including link to objectives) The purpose of this report is to provide assurance to the Trust Board that all non-clinical risks are appropriately identified, assessed and managed 2. Summary of Key Issues for Discussion New risks identified to be added to the risk register Risks to be removed from the register Polices approved Audit reports with limited assurance Developments required to reports to NCRC to improve assurance Request to nominate a Non Executive Director to be responsible to the Board for NHS security management. 3. Recommendations (Note, Approve, Discuss etc) The Trust Board is asked to: 1. Note the report and to agree any further actions required to mitigate or eliminate risks or improve assurance. 2. Agree to the removal of Risk Numbers 29, 44, 47, 50, 52, 56, 65, 108, 124, 132, 143, 155, 165, 168 from the risk register. Nominate a Non Executive Director to be responsible to the Board for NHS security management. 4. Standards for Better Health (which apply) C4b,C5b,C5c,C7a&c, C7b,C7e,C8a, C8b,C10a,c10b,c11a,C11b,C11c,c20a,C23, Author : Lynn Vaughan, Director of Human Agenda Item: 4.1 Page 1 of 5

2 5. Legal / Regulatory Implications (NHSLA / ALE etc) NHLA standards 1, 2, 3,5, 6. Risk (Threats or opportunities link to risk on register etc) As identified in the report. 7. Implications (Financial / staffing) Impact of achieving compliance with Fire Regulations and Disability Discrimination Act. Requirements to increase training provision in a range of areas to mitigate potential risks 8. Equality and Diversity The Strategic Health Authority (SHA) web based audit of compliance with the legislative publications requirement between 8 th June and 3 rd July The implications of the Equality Bill, which is progressing through the committee stage. 9. Communication Information Governance Serious Untoward Incident. 10. References to previous reports Trust Board Reports. 11. Freedom of Information Public Author : Lynn Vaughan, Director of Human Agenda Item: 4.1 Page 2 of 5

3 NON CLINICAL RISK COMMITTEE (NCRC) REPORT 1. OUTSTANDING ACTIONS APPENDIX 1 The Committee reviewed a range of outstanding actions and required key individuals to progress and report back to the Committee. 2. FIRE ACTION SURVEY & DDA REPORT A detailed report was considered and the Committee noted significant work was required to achieve compliance; some items will be dealt with as part of the major capital programme. Risks will be entered onto the risk register under two headings, Fire and Disability Discrimination Act. Increasing management accountability and increased training were important actions to improve compliance. 3. TRAINING CAPACITY PLAN The Committee noted issues and risks regarding organisational capacity to deliver mandatory training and agreed that a short term focus group would be tasked with resolving the problems and the risk should be entered onto the risk register. 4. RISK REGISTER The Committee agreed to recommend to the Trust Board, closure of the following Risk Numbers: 29, 44, 47, 50, 52, 56, 65, 108, 124, 132, 143, 155, 165, HEALTH & SAFETY COMMITTEE The Committee noted a range of policy development work and reports. Further work to develop training provision was identified. Author : Lynn Vaughan, Director of Human Agenda Item: 4.1 Page 3 of 5

4 6. INFORMATION GOVERNANCE COMMITTEE The Committee noted a range of work on information governance. An audit had been undertaken and a Limited Assurance outcome given in terms of corporate records management; an action plan for resolution is in place. There have been no Serious Untoward Incidents (SUI) since the last meeting however it was identified that the last SUI that occurred in the Trust in May 2008 resulted from a patient clinic list being found in a supermarket car park. This incident did not follow the correct process for escalation to SUI status. In future each report to the Committee will state if a SUI has taken place and that it has been reported accordingly. 7. WORKFORCE ASSURANCE, RISKS & INCIDENTS REPORT Positive progress was reported on a range of matters, although staffing levels affecting care remains the second highest reported incident type. It was agreed that new employment tribunal claims would be signalled to the NCRC in future reports. 8. EQUALITY & DIVERSITY ASSURANCE REPORT The Committee noted that the SHA will undertake a web based audit of compliance with the legislative publications requirement between 8 th June and 3 rd July The implications of the Equality Bill, which is progressing through the committee stage will be presented to the Management Board in September. There are currently four equal pay cases against the Trust in respect of back pay prior to Agenda for Change. Increasing awareness of equality and diversity remains an important action to mitigate risks to the Trust from the behavior of individuals. 9. POLICY APPROVAL 9.1 Media Handling Policy Author : Lynn Vaughan, Director of Human Agenda Item: 4.1 Page 4 of 5

5 The Committee requested further work prior to approving this policy. 9.2 Trust wide policy for the development and management of procedural documents Approved. 10. MATTERS REFERRED FROM OR TO AUDIT COMMITTEE, CLINICAL GOVERNANCE COMMITTEE OR MANAGEMENT BOARD Items referred from the Audit Committee due to limited assurance were: a. SAS Contracts b. Theatres System c. Corporate Records Management The Committee requested that the recommendations be followed up as a matter of urgency and that any action plans/issues be brought back to the Committee, if necessary. 11. NHS SECURITY MANAGEMENT NOMINATION The Committee noted the request to nominate a Non Executive Director to be responsible to the Board for NHS security management. This would be referred to the Trust Board. Author : Lynn Vaughan, Director of Human Agenda Item: 4.1 Page 5 of 5