Strategic Objectives (SOs) Integrated Finance, Operations and Delivery. Ensuring Quality (Effectiveness, Experience & Safety. Strategic Objective 6

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1 Consequence NHS South Yorkshire and Bassetlaw Framework v1.3 as at Key notes: The Framework has been developed in accordance with guidelines provided by the Department of Health, Internal Audit and the Strategic Health Authority and comprises risks which affect the achievement of the NHS South Yorkshire & Bassetlaw s strategic objectives, vision and values. Only those potential or current risks which affect the achievement of NHS South Yorkshire & Bassetlaw s strategic objectives are eligible for entry to the Framework. All other risks are managed through the Risk Register, and each of the Risk Register risks is linked to an overarching Framework risk. Risks can be a) treated (via an action plan), b) tolerated, c) terminated or d) transferred (e.g. to another organisation). Leads named on the Framework review the controls, assurances, gaps in control/assurance and scores of the Framework risks on a regular basis. The Framework Risk Lead(s) for each area, in consultation with the Governance Lead(s), can add or remove risks from the Framework. This will be subsequently ratified by the NHS South Yorkshire & Bassetlaw Board. The organisational risk appetite under which risks can be tolerated is a score of 11 or below. Risks scored at or in excess of a score of 16 should be notified by exception to the Board by Director Leads. The Strategic Objectives against which the Framework is currently mapped and risk scoring matrix are shown below. Strategic Objectives (SOs) Strategic Objective 1 Strategic Objective 2 Strategic Objective 3 Strategic Objective 4 Integrated, Operations and Delivery Development Ensuring Quality (Effectiveness, Experience & Safety Emergency Planning & Resilience Risk Matrix (1) Rare (2) Unlikely Likelihood (3) Possible (4) Likely (5) Almost certain (1) Negligible (2) Minor (3) Moderate (4) Major (5) Extreme Strategic Objective 5 Strategic Objective 6 Elements of Provider Development Communication and Engagement 1-5 Low The risk appetite under which risks 6-11 Medium can be tolerated is a score of 11 or below High Risks scored at or in excess of a Very High score of 16 should be notified by 25 Extreme exception to the Board.

2 The Framework columns include: Area s Uncontrolled risk Current Risk Positive Gaps in Control and Outcome Date Definition Those risks which affect the achievement of the NHS South Yorkshire & Bassetlaw s strategic objectives. The risk score (consequence x likelihood) if there were no controls in place. This helps the organisation to prioritise risks. The risk score (consequence x likelihood) as at the present time with the listed controls in place. See appendix for the detailed risk scoring matrix. The controls which are already in place to control the risk and reduce its likelihood of occurring. Controls can be: Preventative (stopping the risk occurring e.g. access controls) Detective (If the risk is threatening to occur, how would you know? e.g. authorisation process) Directive (instructions or guidance in place to reduce the chance of the risk occurring e.g. policies) The assurances which are in place to check that the key controls for the risk are operating effectively e.g., audits. s are broken down into internal assurances such as internal, and external assurances such as the independent Internal Audit Reports. The positive assurances which have been received that confirm the risk is being effectively managed, and that key controls are in place and working e.g. positive Internal or External Audit Reports. The gaps identified in control or assurance, which, if addressed, would reduce the risk score. The risk treatment which is appropriate for the risk based on the risk description, the scoring and any gaps in either control or assurance. There are 4 categories to choose from: Treat Where there are insufficient controls and/or assurances in place, risks must be treated. Any risk scored with a risk rating of 12 or above should be treated. The risk treatment should be captured in an accompanying action plan. Tolerate Where the risk is deemed adequately controlled and there are sufficient assurances in place, risks can be tolerated providing that they are scored with a risk rating of 11 or below. Transfer Risks can be transferred to another organisation, therefore removing the associated risk e.g. transfer of commissioning decisions, transferring services or letting contracts with risk transfer clauses. Terminate It could be that the organisation wishes to avoid a particular risk altogether. This may involve ceasing the activity giving rise to the risk. Risks should be reviewed at least 6-monthly. 2

3 NHS South Yorkshire and Bassetlaw Framework v1.3 as at Ref Lead Person / Objective 1 - Integrated, Operations & Delivery 1.1 Failure to deliver Financial Strategy and financial targets resulting in failure to meet control totals and statutory financial duties. Uncontrolled risk Current Risk Standing Instructions, Standing Orders and Schemes of Delegation Chief Officers Local governance governance Meetings between Director of and Chief Officers Executive Team meetings with Chief Operating Officers Monthly Reporting process to Board Internal Financial Board Internal Audit Handover Reports from PCTs External Statements of Internal Control for each locality Positive Gaps in Control Gaps in Outcome Board Reports Continuing Health Care Prescribing Fraud Impact of partner disinvestment on NHS budgets Continue to regularly monitor financial outcomes across the localities. Next Date 1.2 Failure to deliver the financial aspects of the QIPP agenda QIPP Plans for each locality QIPP monitoring as part of monthly Reporting process to Board. Financial Board Reports QIPP Trackers SAAP Handover Reports from PCTs Strategic Health Authority review meetings and letters confirming outcomes Strategic Health Authority review meeting outcomes Department of Health assessment and monitoring process 5 plans across the nondelivery of 1 could lead to failure across the of delivery of plans Continue to monitor QIPP delivery across the localities 3

4 Ref 1.3 Failure to deliver key performance targets resulting in poor patient experience and reputational impact. Lead Person / and Accountability & Uncontrolled risk Current Risk Locality performance monitoring mechanisms Report to Single Board well established and integrated across localities Reports to SHA Director of meets regularly with locality Leads. Internal Report to Single Board External Weekly and monthly SAAP accountability process 6-weekly review with Strategic Health Authority Positive Gaps in Control Gaps in Outcome Reports Weekly SAAP report Systematisting the collation of performance data across the of systematic performance monitoring across the. TOLERATE Systematise the collection of performance data across the localities Next Date 1.4 Failure to procure effectively and collaboratively in line with the regulatory framework resulting in potential legal challenge Procurement Leads / Teams locally Standing Financial Instructions Trust sealing reported to Board Local audit assurances Audit Process for appeal / challenge locally Effective divestment of Bassetlaw Provider Arm and sign-off of Sheffield LIFT Scheme Working collaboratively using shared resources of collaborative working in procurement TOLERATE 1.5 Failure to use all available data effectively to plan services robustly leading to ineffective commissioning / decommissioning and gaps in service. and Accountability Joint Strategic Needs Assessments Public Health Data Health Observatories Single Operating Plans Health Needs Assessments Local systems in localities External data validation Single & Accountability Process (SAAP) JSNAs in all localities TOLERATE Objective 2 - Development 2.1 Failure to ensure effective to move to the new NHS architecture by April Chief Executive Local commissioning Local governance governance Local partnership transition plans Management of Change Policy Confirm & Challenge Authorisation process (in draft) Local Lack of clarity around statutory functions transferring to new organisations Health & Social Care Bill still in draft Lack of clarity on what a Support Unit will deliver across the Lack of established CCG in Barnsley Action Plan: Develop Transition Plan including NHS Commissionin g Board, Public Health and CCG Authorisation 4

5 Ref 2.2 Failure to directly commission for specialised services during transition: Specialised FHS and Primary Care Contracting Offender Health and Military Health Lead Person / Interim Director of Support Services Development & Directors of SCG Uncontrolled risk Current Risk Local systems in place across localities finance, performance & quality Contracts locally Internal Quality Outcome Framework Data validation Internal Audit Reports SCG to Contract monitoring External Patient satisfaction and QOF data Next Date TOLERATE Positive Gaps in Control Gaps in Outcome Reports to Single Board Minutes of meetings to Systematising across the 5 localities Lack of national clarity 2.3 Failure to ensure Clinical Group capability and capacity, including wider clinical engagement leading to non-authorisation of Clinical Groups. Clinical Group Development Local commissioning Local governance governance Local partnership Confirm & Challenge Authorisation process (in draft) Local Well established PCTs as current statutory bodies Some areas of good practice Clarity on what a CSU will deliver across the Variation across the patch on engagement Lack of established CCG in Barnsley Coordinate plans across the localities to ensure authorisation of CCGs in line with national timescales. 2.4 Recent national publication of a call for retrospective Continuing Healthcare claims is expected to lead to a significant increase in claims impacting on both staffing capacity to review the claims and on finance. The time limits for the process are very short September. Nurse Director Project Plans in place to address staffing and process. reporting regime Financial reporting regime Communications Plan Report monthly to Board including areas of increasing risk Unknown volume of claims resulting from national publication Develop a coordinated approach to Continuing Care retrospective claims reviews Objective 3 - Ensuring Quality 3.1 Failure to ensure effective patient safety, quality and assurance processes are in place resulting in potential poor patient experience. Nurse Director Local patient safety Quality Leads working across Patient Safety Dashboard including Serious Incidents (SIs) Quality & Patient Safety at and local level Quality schedules in contracts Maintaining High Professional Standards Reference Group and local structures Patient Safety Dashboard Quality & Patient Safety Group minutes Reporting mechanisms Monitoring Maintaining High Professional Standards Reference Group minutes Care Quality Commission registration and inspection Monitor PEAT scores Staff Survey Patient Survey Quality Accounts Feedback from Overview & Scrutiny SI reporting Patient Safety dashboard Quality Framework for home care and nursing and residential homes not systematic across all localities C diff trajectory is non deliverable across the Monitor through Risk Register and local 5

6 Ref 3.2 Failure to obtain and use patient experience data effectively resulting in potential poor patient experience. Lead Person / Uncontrolled risk Current Risk Nurse Director Local systems for capturing and feeding in patient experience data Joint Strategic Needs Assessment Equality Act compliance Quality & Patient Safety and mirror group in localities Patient engagement groups and activities LINks on Single Board Internal Complaints monitoring SI Patient Safety Report issues by exception External Feedback from Overview & Scrutiny Ombudsman Report LINks and CVS feedback Next Date TOLERATE Positive Gaps in Control Gaps in Outcome Locality in place and being enhanced via Equality Delivery System work Inconsistency in number of PPI Leads across the 3.3 Failure to ensure robust systems of Risk Management & Governance are in place, not fulfilling statutory responsibilities. HR & Governance and local Governance structures agreed Scheme of Delegation Executive Team Standing Financial Instructions Roles and responsibilities of executive team agreed Terms of Reference Partnership working by locality Governance Leads across Audit Audit Groups in each locality Quality & Patient Safety Quality & Safety Groups in each locality Confirm & Challenge Existing Frameworks and Risk Registers Annual Governance Letter Statement of Internal Control Annual Governance Statement Internal Audit Reports Alignment of relevant probity policies Information flows between s and Groups Risk of local governance form not following function during transition cycle Evaluation of effectiveness of Work to align governance across localities wherever practicable 3.4 Failure to effectively plan and enact Public Health transition to the Local Authority leading to wider health inequalities. Directors of Public Health Directors of Public Health Financial return to SHA on public health finances Transition plan Partnership work with Health & Wellbeing Board Monitoring on transition plan Local for Public Health Local transition in place Lack of national clarity Unknown financial risk TOLERATE 6

7 Ref 3.5 Failure to effectively safeguard children and vulnerable people in line with statutory requirements leading to potential harm. Lead Person / Uncontrolled risk Current Risk Nurse Director Local safeguarding boards / Safeguarding Professionals in post Safeguarding Policies and Procedures Mandatory training Internal Safeguarding checklist Safeguarding Annual Reports Reports to Quality & Patient Safety and local mirror group Training monitoring External Ofsted Inspections Serious Case s and SI / IMRs Homicide s Positive Gaps in Control Gaps in Outcome Child Death Overview Panels Interim in place for safeguarding professionals Action Plan Monitor through Risk Register and local Next Date 3.6 Failure to ensure effective workforce planning and capability leading to demotivation of staff. HR & Governance Plans for alignment of staff PDR & KSF process HR policies and procedures Staff training Local Staff Side / JNCC locally and at Management of Change Policy HR reporting to SMT or equivalent Staff Survey OD Plan Assignment of staff to CSS / CCG Communication to staff / perceptions of staff re equality of opportunity for appointments TOLERATE Objective 4 - Emergency Planning & Resilience 4.1 Failure to have effective Emergency Planning in place, resulting in a failure to meet statutory duties under the civil contingencies act. Interim Director of Support Services Development and Accountability Lead PCT Local emergency planning in all 5 localities Gold Command across the 2 Local Resilience Forums Representation at both Local Resilience Forum subgroups Emergency Plans covering all national and local risks Exercises and training Pandemic Flu Plans Self-assessments Internal Audit De-brief incidents and exercises with action plans. E,g, H1N1 de-brief. Successful test of Silver and Gold Command processes across National Capability Survey locally and across Local Resilience Forums Management of recent episodes e.g. flu and snow National lack of clarity re direction for emergency planning and the role of CCGs / CSSs TOLERATE 7

8 Ref 4.2 Failure to effectively plan for Seasonal Pressures, therefore not responding effectively to patient need Lead Person / and Accountability Uncontrolled risk Current Risk Local and regular local meetings Winter Leads Seasonal Plans Contracts Reporting and escalation mechanisms in place Internal Daily situation from 1 st November Local and to SHA Reports to Board Successful test of Silver and Gold Command processes across External SHA Positive Gaps in Control Gaps in Outcome Locality responses to seasonal pressures Due to reconfiguration across the patch the immediacy of the response to business continuity situations has not been tested across the health economy Systematic management of and reporting from Foundation Trusts across the patch planned but not implemented TOLERATE Implementation of process from 1 st November followed by testing of plans Next Date Objective 5 - Elements of Provider Development 5.1 Failure to effectively manage and engage with Providers during transition and following reconfiguration to ensure continuity of commissioned services and contract management and Accountability & Interim Director of Support Services Development Contracts intentions Local contract negotiation frameworks and processes Quality indicators in contracts Ambulance FT Pipelines managed through Lead Commissioners (not in SY ) Signing of contracts Any Qualified Provider process commenced Reports locally and to Board Contract and quality monitoring Local assurance processes Signed contracts Audit Commission Contracts in place and monitored Potential capacity and capability to manage the contracting framework Lack of national clarity regarding Any Qualified Provider TOLERATE Treat as risks emerge Objective 6 - Communication and Engagement 6.1 Failure to effectively engage staff systematically during transition, resulting in potential de-motivation, lack of productivity and poor staff experience and including potential industrial action HR & Governance HR Service Staff Survey Communication from Chief Executive to staff Staff Briefings locally Rotation of location of Board meetings Department of Health HR guidance Appraisal and PDP processes 1:1s with Managers Management of Change Policy Staff Side Forum across HR reporting locally Staff Survey Shared working in HR functions locally and across the Low sickness levels Application of a transparent and systematic HR framework Localities are at different stages in local staff management processes e.g. voluntary redundancy Lack of national clarity regarding Workforce direction Planned strike unknown level of support Work to align workforce systems and processes across the localities 8

9 Ref 6.2 Failure to engage effectively with patients, the public and seldom heard groups in line with the NHS Constitution resulting in potential disengagement, discrimination and health inequalities Lead Person / HR & Governance Uncontrolled risk Current Risk Patient engagement plans Single Equality Schemes in each locality and plans to move to Equality Delivery System selfassessment Publishing of equality data by January Equality Delivery System used in each locality to develop and publish scores and Equality Objectives Communications Lead at coordinating across localities Internal Consultation on Clinical Services LINks meetings and events Equality Delivery System engagement feedback and minutes of Equality Leads meeting External Internal Audits Next Date TOLERATE Positive Gaps in Control Gaps in Outcome Single Equality Scheme monitoring via core equality data set 9

10 NHS South Yorkshire and Bassetlaw Framework Action Plan Ref 1.1 Failure to deliver Financial Strategy and financial targets resulting in failure to meet control totals and statutory financial duties. Lead Person / Uncontrolled risk Current Risk Action Plan Progress Due Date Continue to regularly monitor financial outcomes across the localities Report received monthly by Board. Monitoring ongoing. Localities have plans in place to meet year-end control totals report continues to be received monthly by Trust Board. Statutory financial duties expected to be met. Action timescale extended to to cover annual accounts. 1.2 Failure to deliver the financial aspects of the QIPP agenda Continue to monitor QIPP delivery across the localities Report received monthly by Board. Monitoring ongoing. Localities have plans in place to meet year-end control totals. Clinical Groups are working on QIPP commissioning intention priorities for / report continues to be received monthly by Trust Board including QIPP. Statutory financial duties expected to be met. Action timescale extended to to cover annual accounts and alignment of QIPP Plans /13 across the. Risk likelihood reduced to a level of Failure to deliver key performance targets resulting in poor patient experience and reputational impact. & Accountability & Systematise the collection of performance data across the localities Report received monthly by Board. Monitoring ongoing. Localities have plans in place to address performance issues. High risk areas are A&E and Ambulance targets Reporting established and received monthly by Board. Local systems in place for addressing performance issues which are reported to Board. & Accountability meets regularly with local Leads to ensure effective communications. Reduce likelihood score to a level 2 and close risk. CLOSED 2.1 Failure to ensure effective to move to the new NHS architecture by April Chief Executive Develop Maintain Transition Plan including NHS Board, Public Health and CCG Authorisation Locality plans in place e.g. Public Health transition. Reports are brought together at Board Transition plans in place at and Locality level. Risk remains in /13 following Royal Assent to the Health & Social Care Bill. Change action to maintain transition plan and extend due date to Failure to ensure Clinical Group capability and capacity, including wider clinical engagement leading to non-authorisation of Clinical Groups. Clinical Group Development Coordinate plans across the localities to ensure authorisation of CCGs in line with national timescales Minutes of the 4 existing Clinical Groups are received by the Board for assurance CCG plans for authorisation are in place at and Locality level, however local risks remain into /13. Reword action plan and extend due date to Additional gap in control: lack of CCG in Barnsley Failure to ensure robust systems of Risk Management & Governance are in place, not fulfilling statutory responsibilities. HR & Governance Work to align governance across localities wherever practicable Governance Leads are meeting monthly. Framework developed and agreed November Risk Register to be received January. Alignment of key prioritised policies is underway e.g. Standards of Business Conduct Governance Leads continue to work together on key areas of governance. Annual Governance Statements required in line with annual accounts. Action timescale extended to to cover this timescale. Following completed Annual Governance Statements, risk should reduce to a likelihood of Failure to effectively safeguard children and vulnerable people in line with statutory requirements leading to potential harm. Nurse Director Monitor through Risk Register and local Quality & Patient Safety receives regular on safeguarding. Serious Untoward Incidents reviewed and Exception Reported to Board Systems in place through Quality Reporting. Increased reputational risk currently due to J Children case publicity in Doncaster, therefore retain risk at this level for a further 3 months. 10

11 Ref 4.2 Failure to effectively plan for Seasonal Pressures, therefore not responding effectively to patient need. Lead Person / and Accountability Uncontrolled risk Current Risk Action Plan Progress Due Date Implementation of process from 1 st November followed by testing of plans Silver and Gold On Call rota established from October Seasonal Pressures meetings held in localities. Resilience received by Board System implemented in Quarter 3 and has been running effectively. A test has taken place of Silver and Gold Command and lessons learned. Reduce risk likelihood score to a level of 2 and close action plan. CLOSED 6.1 Failure to effectively engage staff systematically during transition, resulting in potential de-motivation, lack of productivity and poor staff experience and including potential industrial action HR & Governance Work to align workforce systems and processes across the localities HR policies have been prioritised for alignment, commencing with Management of Change, Disciplinary & Grievance and Special Leave Management of Change Policy has been updated to reflect VR/VER Scheme etc. Remainder of policies are in draft. Timeframe extended to September to cover work towards CSS. 30 th September 11

12 Risk Scoring Matrix Appendix A Table 1 Consequence score (C) Choose the most appropriate domain for the identified risk from the left hand side of the table. Then work along the columns in same row to assess the severity of the risk on the scale of 1 to 5 to determine the consequence score, which is the number given at the top of the column. Consequence score (severity levels) and examples of descriptors Domains Negligible Minor Moderate Major Extreme Patient and staff safety Quality Human Resources / Organisational Development Minimal injury requiring no / minimal intervention or treatment. No time off work Peripheral element of treatment or service suboptimal Informal complaint/ inquiry Short-term low staffing level that temporarily reduces service quality (< 1 day) Minor injury or illness, requiring minor intervention Requiring time off work for >3 days Overall treatment or service suboptimal Formal complaint Local resolution Single failure to meet internal standards Minor implications for patient safety if unresolved Reduced performance rating if unresolved Low staffing level that reduces the service quality Moderate injury requiring professional intervention Requiring time off work for 4-14 days. RIDDOR reportable incident An event which impacts on a small number of patients Treatment or service has significantly reduced effectiveness Local resolution (with potential to go to independent review) Repeated failure to meet internal standards Major patient safety implications if findings are not acted on Late delivery of key objective/ service due to lack of staff Unsafe staffing level or competence (>1 day) Low staff morale Poor staff attendance for mandatory/key training Major injury leading to long-term incapacity / disability Requiring time off work for >14 days Mismanagement of patient care with long-term effects Non-compliance with national standards with significant risk to patients if unresolved Multiple complaints / independent review Low performance rating Critical report Uncertain delivery of key objective/service due to lack of staff Unsafe staffing level or competence (>5 days) Loss of key staff Very low staff morale No staff attending mandatory/ key training Incident leading to death Multiple permanent injuries or irreversible health effects An event which impacts on a large number of patients Unacceptable level or quality of treatment / service Gross failure of patient safety if findings not acted on Inquest / ombudsman inquiry Gross failure to meet national standards Non-delivery of key objective/service due to lack of staff Ongoing unsafe staffing levels or competence Loss of several key staff No staff attending mandatory training /key training on an ongoing basis 12

13 Consequence score (severity levels) and examples of descriptors Domains Negligible Minor Moderate Major Extreme Enforcement action Multiple breeches in statutory duty Statutory duty / inspections Adverse publicity / Reputation Business Objectives Service / business interruption Impact on environment No or minimal impact or breech of guidance/ statutory duty Rumours Potential for public concern Insignificant cost increase / schedule slippage Small loss Risk of claim remote Loss/interruption of >1 hour Minimal or no impact on the environment Breech of statutory legislation Reduced performance rating if unresolved Local media coverage short-term reduction in public confidence Elements of public expectation not being met <5 per cent over project budget Schedule slippage Loss of per cent of budget Claim less than 10,000 Loss/interruption of >8 hours Minor impact on environment Single breech in statutory duty Challenging external recommendations / improvement notice Local media coverage long-term reduction in public confidence 5 10 per cent over project budget Schedule slippage Loss of per cent of budget Claim(s) between 10,000 and 100,000 Loss/interruption of >1 day Moderate impact on environment Multiple breeches in statutory duty Improvement notices Low performance rating Critical report National media coverage with <3 days service well below reasonable public expectation Non-compliance with national per cent over project budget Schedule slippage Key objectives not met Uncertain delivery of key objective/loss of per cent of budget Claim(s) between 100,000 and 1 million Purchasers failing to pay on time Loss/interruption of >1 week Major impact on environment Prosecution Complete systems change required Zero performance rating Severely critical report National media coverage with >3 days service well below reasonable public expectation. MP concerned (questions in the House) Total loss of public confidence Incident leading >25 per cent over project budget Schedule slippage Key objectives not met Non-delivery of key objective/ Loss of >1 per cent of budget Failure to meet specification/ slippage Loss of contract / payment by results Claim(s) > 1 million Permanent loss of service or facility Extreme impact on environment 13

14 Consequence Table 2 Likelihood score (L) What is the likelihood of the consequence occurring? The frequency-based score is appropriate in most circumstances and is easier to identify. It should be used whenever it is possible to identify a frequency. Likelihood score Descriptor Rare Unlikely Possible Likely Almost certain Frequency How often might it / does it happen Probability Percentage likelihood of occurrence This will probably never happen/recur Do not expect it to happen/recur but it is possible it may do so Might happen or recur occasionally Will probably happen/recur but it is not a persisting issue Will undoubtedly happen / recur, possibly frequently 0-5% 6-20% 21-50% 51-80% % Table 3 Risk scoring = consequence x likelihood ( C x L ) Calculate the risk score by multiplying the consequence score by the likelihood score. Risk Matrix (1) Negligible (2) Minor (3) Moderate (4) Major (5) Extreme 1-5 Low 6-11 Medium High Very High 25 Extreme (1) Rare (2) Unlikely Likelihood (3) Possible (4) Likely (5) Almost certain The risk tolerance/appetite under which risks can be tolerated is a score of 11 or below where the assessment has been undertaken following the implementation of controls and assurances. 14