XXXXXXX, Director of Strategy and Transformation XXXXXX, Senior Governance Manager, Senior Governance Manager (Risks and Incidents)

Transcription

1 Corporate Risk Register Report Month Year EECUTIVE SUMMARY REPORT TO: DATE: AGENDA NO: AGENDA ITEM: SPONSOR: PREPARED BY: PRESENTED BY: Risk Management Committee Month Year., Director of Strategy and Transformation, Senior Governance Manager, Senior Governance Manager (Risks and Incidents), Senior Governance Manager, Senior Governance Manager (Risks and Incidents) 1. Purpose and Key Issues 1.1. The purpose of this paper is to bring to the attention of the Risk Management Committee any further updates and items or themes to note from the routine reports of the Corporate Risk Register this month. Key Issues include: There have been New Risks added to the Corporate Risk Register There have been risks that have had their action plans completed since Month Year There have been risk exceptions There have been No responses to risk updates 2. Supporting Information 2.1. The report is attached. 3. Controls and Assurance 3.1. The Risk Management Committee is to manage and monitor all aspects of clinical and nonclinical risk within the Northern Devon Healthcare NHS Trust. 4. Legal and Regulatory Implications 4.1. Robust risk management processes and management of incidents enable the Trust to meet the legal requirements of the Health and Safety at Work Act (1974) and the management of Health and Safety at Work Regulations (1999)

2 Executive Summary - 5. Equality and Diversity Implications 5.1. The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. No adverse or positive impacts have been identified from this report. 6. Patient, Public and Staff Engagement 6.1. The Trust ensures that patients, the public and staff are involved in the decision-making process when appropriate. Membership of the Risk Management Committee includes staff and Non Executive Directors. 7. Cost Implications 7.1. There are no cost implications. 8. Potential Risk to the Organisation 8.1. There is a risk to the trust not complying with best practice, and internal and external controls if the risk management arrangements are not managed. 9. Committee Prompts Is the Risk Management Committee assured that the new risks have been scored appropriately? Does the Risk Management Committee approve the risk exceptions? Does the Risk Management Committee accept the residual risk for closed risks? Is the Risk Management Committee assured that No responses to risk updates have been followed up effectively? 10. Recommendations The Committee is asked to RECEIVE the report. 11. References None 12. Strategic Objectives The Trust s strategic objectives are reviewed by the Board on an annual basis. This paper supports the achievement of the following strategic objectives: Highest Quality Flexible and multi-skilled workforce Sustainable Services Efficient & Effective Integrated Health & Social Care Provider of Choice :\INFORMATION GOVERNANCE\FOI\ \nos \FOI Risk Management at Corporate Level\NDHT RMC Corporate Risk Register Report Blank Template.docx Page 2 of 13

3 Executive Summary Principal Risks The Trust s principal risks have been identified through the Trust s risk management processes. They are updated as they are identified by the Risk Management Committee. This paper supports the mitigation of the following principal risks : Financial planning & management Clinical records management Strategic & business planning Leadership & management Workforce numbers Unsafe behaviour Workforce skills External demands Procedural management Partnership arrangements Equipment & facilities arrangements Communication :\INFORMATION GOVERNANCE\FOI\ \nos \FOI Risk Management at Corporate Level\NDHT RMC Corporate Risk Register Report Blank Template.docx Page 3 of 13

4 Corporate Risk Register Report Month Year Corporate Risk Register Report This report describes new risks, accepted risks and 15+ risk exceptions since the last report and items and themes from the routine reports to bring to the attention of the Risk Management Committee. Risk Team Corporate Governance Department Published Date Month Year

5 CONTENTS 1. Purpose Background New risk report Accepted Risks Report Exceptions Report Risks (All scores) Open Risk Profile :\INFORMATION GOVERNANCE\FOI\ \nos \FOI Risk Management at Corporate Level\NDHT RMC Corporate Risk Register Report Blank Template.docx Page 5 of 13

6 1. Purpose 1.1. This report is to bring to the attention of the Risk Management Committee any further updates and items or themes to note from the routine reports of the Corporate Risk Register this month. 2. Background 2.1. This is a routine report provided at each Risk Management Committee meeting held monthly (apart from January and August). 3. New risks report 3.1. New Risks new risks have been added to the Corporate Risk Register since Date Month Year. In accordance with the Risk Team s protocols, monthly reports of new risks that have been entered on to the corporate risk register are circulated to the directors, relevant senior managers and the risk leads and action plan leads for information. These reports also include details of the current controls in place which have been considered when the risk has been scored and any actions identified to mitigate the risk. Figure 1: Number of new risks by Initial Score. Initial Risk Score Low (1 6) Medium (8-12) High (15+) Total Number of New Risks xx xx xx xx Open New Risks There are new open risks with an initial score of 15+ that remain open. Risk ID Risk of..due to.. Initial risk score??=??. Risk Lead: The source of the risk was a. actions have been identified, they include reviewing the. and in the long term evaluating the.. many of the actions have been cross referenced to Risk ID - Risk of due to xxxxx. :\INFORMATION GOVERNANCE\FOI\ \nos \FOI Risk Management at Corporate Level\NDHT RMC Corporate Risk Register Report Blank Template.docx Page 6 of 13

7 3.3. New risks for acceptance There are no new 15+ risks where the action plans have been completed Figure 2 below illustrates the number of new risks by source. It can be noted that xx of the xx (xx%) of new risks were sourced from xxxxxx. Figure 2: Number of new risks added to the Corporate Risk Register by source of risk. Internal Audit, 5 SEA, 5 Risks, 5 SIRI, Figure 3 below illustrates the number of new risks by division. It can be noted that the had the highest number of new risks added at xx of the xx new risks (xx%). The details are described in the New Risks Report Month Year. Figure 3: Number of new risk by Division Number of new risks by Division :\INFORMATION GOVERNANCE\FOI\ \nos \FOI Risk Management at Corporate Level\NDHT RMC Corporate Risk Register Report Blank Template.docx Page 7 of 13

8 3.6. Figure 4 below illustrates the breakdown of the new risks by Division and source of risk. Figure 4: Divisional New Risks by Source 72 Hour SEA SIRI Internal Audit Deep Dive Risks Total Medical Specialities Surgical Specialities Clinical Support Services Emergency Services Community Hospital Health and Social Care Specialist Services Director of Finance Director of Facilities Strategy and Transform Director of Nursing Director of HR Trust- wide Totals x x x x x x 4. Accepted Risks Report 4.1. risks have had their action plans completed since Date Month Year and have been re-scored or the scores confirmed. Risks with scores of 15+ initially accepted by the Risk Management Committee will be recommended to the Audit and Assurance Committee for final acceptance Figure 5 below illustrates the initial and final risk scores. The details are described in the Accepted Risks Report Month Year. Figure 5. Initial and final risk scores Initial Risk Score Low (1 6) Medium (8 12) High (15+) Initial number of risks Final Risk Score Low Medium High Total x x x :\INFORMATION GOVERNANCE\FOI\ \nos \FOI Risk Management at Corporate Level\NDHT RMC Corporate Risk Register Report Blank Template.docx Page 8 of 13

9 4.3. Of these risks, had an initial rating of 15+: Risk ID Risk of... Initial score?x?=??. Risk Lead: All actions have been completed, The risk has been rescored to?x?=??. Does the Risk Management Committee accept the residual risk? 4.4. Figure 6 below illustrates the percentage of accepted risks by Division. The details are described in the Accepted Risks Report Month Year. It can be noted that the xxxxx and xxxxxx each had the highest number at xxxx of the xxxx accepted risks (xx%). Figure 6 Number of accepted risks by Division Number of accepted risks by Division 5. Exceptions Report Risks (All scores) 5.1. There were a total of risks where action plan due dates were due to be completed by the end of Month Year and an update request was sent to the risk leads There were a total of xxxxxxxxxxxxxxx exceptions recorded in Month Year. An exception is recorded against a risk when the following occurs: The risk lead extends the due date of an action plan; Action plans are added or reopened; The risk is rescored up or down; The risk lead or action plan lead is changed; There is no response to a request for an update; The risk is reopened or closed due to cross referencing to another risk; or The risk details are incomplete. :\INFORMATION GOVERNANCE\FOI\ \nos \FOI Risk Management at Corporate Level\NDHT RMC Corporate Risk Register Report Blank Template.docx Page 9 of 13

10 5.3. Figure 7 below illustrates the categories of the exceptions. The details are described in the Exceptions Risks Report Moth Year. Figure 7 Risk exceptions Exception Reasons Number of Exceptions xx/xx/xxxx Action plan due date extended Action plan lead changed Action plan re - opened New action plan added Risk Lead changed Risk re- scored Risk re-opened No response to update request Risk Closed cross referenced to another Incomplete risks Total Risks Exceptions Risk ID Risk that the Trust. Current risk score?x? =??. Risk Lead: One action has been exceptioned this month. Action: Update:. The original due date was Month Year. The due date has been extended from the date Month Year to the Date Month Year. Does the Risk Management Committee agree that the exception is reasonable? 5.5. No response to update requests for consecutive months At the date of the Exceptions Report being prepared for this meeting there were a total of risks where no response to a request for an update had been received for one or more consecutive months. :\INFORMATION GOVERNANCE\FOI\ \nos \FOI Risk Management at Corporate Level\NDHT RMC Corporate Risk Register Report Blank Template.docx Page 10 of 13

11 There has been an in the number of no responses since last month from xxx% to xxx %. letters were sent to the risk leads of risks were no response to an update request was provided. It should be noted that a number of risk updates will have been received after the deadline. This information will be presented to the Risk Management Committee via the routine reports. Figure 8. List of risks where there was no response to the request for update was provided ID Current Rating Title Risk Lead Actin plan Lead(s) No Response letter sent - awaiting response No Response meeting letter sent waiting for meeting No Response letter due to be sent Update received after deadline 5.6. Figure 9 below illustrates the number of no responses risks regardless of score by Division and the total number of open risks. The xxxxxx had the most no responses with xx of the xx (xx%), xx of those are from the xxxxx speciality. The details are described in the Exception Report Month Year. Figure 9 No responses by Division Number of no responses and open risks by Division 6. Open Risk Profile 6.1. There are xx 15+ open risks on the Corporate Risk Register. Figure 11 below illustrates the profile of all the open risks for the past six months. Further details of the 15+ risks are available in the 15+ Open Risk Report for Month Year. :\INFORMATION GOVERNANCE\FOI\ \nos \FOI Risk Management at Corporate Level\NDHT RMC Corporate Risk Register Report Blank Template.docx Page 11 of 13

12 Figure 11 Open risk profile for the past 6 months Open Risks Mar 15 Apr 15 May 15 Jun 15 Jul 15 Aug 15 Sep 15 High Risks Moderate Risks Low Risks Totals Open risk profile by source Figure 12 below illustrates the profile of all the open risks by source. General risk assessments are the highest source of open risks on the Corporate Risk Register. :\INFORMATION GOVERNANCE\FOI\ \nos \FOI Risk Management at Corporate Level\NDHT RMC Corporate Risk Register Report Blank Template.docx Page 12 of 13

13 Figure 12. Profile of open risk by source Open Risks SIRI/ Internal SIRI SEA / 72 Hour Report Internal Audit report NPSA RISKS High Risks Moderate Risks Low Risks Totals :\INFORMATION GOVERNANCE\FOI\ \nos \FOI Risk Management at Corporate Level\NDHT RMC Corporate Risk Register Report Blank Template.docx Page 13 of 13