REPORT TO THE AUDIT RISK COMMITTEE

ON THE NHS FIFE CORPORATE RISK REGISTER

18 SEPTEMBER 2014

1.Purpose of report

1.1This report is intended to update the NHS Fife Audit and Risk Committee on the Corporate Risk Register in line with the requirement to submit such a report twice a year.The report highlights key developments in relation to the Register since the last report to the Committee in December 2014.

2.BACKGROUND

2.1 The process for managing the CorporateRisk Register requires that each corporateriskis mapped to the appropriate NHS Fife Governance Committee, aligned to the Quality Ambitions and where applicable, the relevant HEAT targets.

2.2 The Governance Committees are responsible for oversight and scrutiny of such risksand must review these and monitor theirmanagement twice in the year.

2.3 A Programme of Reporting on Corporate Risks to the Governance Committees for 2014 is in place. Thefirst cycle of reporting is complete (see Appendix 1).

3.corporate risk register

3.1The Corporate Risk Register comprises:

  • Strategic risks linked to delivery of the HEAT targets and Quality Ambitions
  • Operational risks which have an organisation-wide impact on care provision
  • Risks escalated from Service, Directorate, Division and CHP Risk Registers whichcannot be adequately managed at these levels

3.2 Currently, the Corporate Risk Register contains 15risks: seven ‘high’ level risks, seven ‘moderate’level risks and one‘low’ level risk. The Register is provided separately.

3.3 Changes in Overall Risk Level

3.3.1 There have been no increases in the overall level of any risk.

3.3.2 Changes in Risk Likelihood

Risk 512 (formerly 3039): Capacity Planning

Since the last time of reporting to the Committee, the likelihood level of the above

risk has increased from ‘likely’ to ‘almost certain’. This is attributed to the recent

increases in the number of patients in delay. This risk will be reported to the Acute

Services Division Committee on 24 September 2014.

.

3.3.3 Reduction in Overall Risk Level

No risk has reduced in overall risk level.

3.4 Risks Closed on the Corporate Risk Register

Since the last report to the Committee, no risk has been closed.

Risk 524 formerly (3205):Modernising Medical Careers

This risk isconcerned with Reshaping the Medical Workforce.Following

considerationat the Staff Governance Committee on 30 April 2014 and subsequent

discussions with the Medical Director,therisk is to be closed as it is no longer

valid.The risk for NHS Fife has moved from Doctors in Training, to the Trained

MedicalWorkforce.A related risk will beworked up and added to the Corporate Risk

Register in due course.

3.5 Risk Added to the Corporate Risk Register:

One risk has been added to the Register since the last time of reporting.

Risk 842:In - patient Falls

A review of in- patient falls revealed some stark data on frequency, severity of harm

and associated morbidity. This was despite considerable efforts made over recent years

toimprove our position on falls and to reduce harm. In June 2014, senior leaders

agreed to take concerted action to address this matter as follows:

  • The reduction of inpatient falls has been identified as the primary strategic priority for quality and safety in NHS Fife for 2014/15. Accordingly it has been agreed that the appropriate clinical, managerial, executive and supporting resources will be aligned to this issue.
  • Rationalisation of the number of groups in Fife dealing with falls,with primacy given to a Board -wide Frailty Steering Group. This group is chaired by Dr Sue Pound and has single decision-making authority. A number of working groups report to the group and may recommend actions but the decision-making authority lies solely with the Frailty Steering Group. It is believed that this will accelerate and enhance progress on improvement.
  • A NHS Fife Falls Summit will take place on 24 September 2014. This will be led by senior clinical, managerial and executive leaders. The summit will focus on action rather than discussion. Delegates will be invited to align themselves with key pieces of SMART and action-focussed work

4. Future Developments

4.1The current arrangements around the Corporate Risk Register will be monitored to ensure they remain fit for purpose and will be modified in line with the evolution of the strategic risk management framework.

4.2 SMThas agreed that a risk related to the health & social careintegration agendawill be added to the Corporate Risk Register.

4.3 An extraordinary session of SMT focussing on risk appetite is being arranged. This will be

externally facilitated as part of the ongoing SMT development sessions.

Following on from this, a Board Development session will be planned. This will be facilitated

by the Director of Nursing (Executive Lead for Risk Management). These events will

provide the opportunity for horizon scanning and act as a catalyst for a refresh of the

Corporate Risk Register.

4.4 A key development in relation to the Corporate Risk Register will be the establishment of a Board Assurance Framework (BAF).This will seek to link strategic risks that could impact on the delivery of organisational objectives, the controls in place to reduce or manage these risks, and assurances that demonstrate whether the controls are having the desired effect. An integral feature of the BAF is the linking of all corporate risks to the appropriate strategic objectives. This development will be therefore be taken forward following the identification of NHS Fife’s strategic objectives.

5.GOVERNANCE

5.1 Staff Governance

Where relevant, the Corporate Risk Register reflects risks relating to reflect NHS Fife’s responsibilities under the Staff Governance Standard.

5.2 Clinical Governance

In addition to being considered by SMT, reports on Clinical Governance risks are reported as appropriate to the Clinical Governance Committees of NHS Fife.

5.3 Financial Governance

The Corporate Risk Register highlights any risks relating to finance.

5.4 Equality & Diversity

Any specific equality and diversity issues in relation to individual risks are covered in the associated management actions.

5.5 PFPI

The Corporate Risk Register reflects risks linked to the quality ambitions and the delivery of the local delivery plan and in managing these, takes cognisance of the need for patient and public involvement as appropriate.

6.RISK MANAGEMENT

6.1The Board is responsible for risk management at a strategic level and is required to have robust systems in place to ensure that it can discharge this responsibility. The development and management of the Corporate, Divisional, CHP,and local risk registers, are essential components of our approach to managing risk.

7. BEST VALUE

7.1 Best Value, pervades all aspects of the Board’s operations and governance structures; within our overall Best Value Framework document the aim is to identify the Committee that is responsible for providing lead governance assurance on the relevant characteristic of Best Value. Through its business and reporting arrangements, SMT addresses the characteristics of ‘Sound Governance at a Strategic and Operational Level’ through elements of performance as evidenced by Board and Committee consideration of the Balanced Scorecard and ‘Contribution to Sustainable Development’ through the elements of Objectives and Plans as evidenced by the Balanced Scorecard.

8. RECOMMENDATION

8.1 Audit & Risk Committee Members are asked to:

  • note the content of this report

Professor Scott McLean

Director of Nursing, NHS Fife

Pauline Cumming

Risk Manager, NHS Fife

Report to the NHS Fife Audit & Risk Committee on 18 September 2014 on the Corporate Risk Register / V1.0 / 26 August 2014
Pauline Cumming / Page 1 of 6

Appendix 1

PROGRAMME OF REPORTING ON CORPORATE RISKS TO THE GOVERNANCE COMMIITTEESOF NHS FIFE 2014

Corporate Risk / Risk Owner / SMT * / Committee / Date / Y/N / SMT * / Committee / Date / Y/N
525 (Formerly 2599 (Equality & Diversity) / S McLean (formerly S Manion) / 24 Feb 2014 / PFPI / 5 Mar 2014 / Y / 25 Aug 2014 / PFPI / 3 Sept 2014
518 (Formerly 3039 (Resilience) / E Coyle / 10 Mar 2014 / Public Health Governance / 18 Mar 2014 / Y / 1 Sept 2014 / Public Health Governance / 11 Sept 2014
528 (Formerly 1193 (Pandemic Flu ) / E Coyle / 10Mar 2014 / Public Health Governance / 18 Mar 2014 / Y / 1 Sept 2014 / Public Health Governance / 11 Sept 2014
524 (Formerly 3205 (MMC) / B Montgomery / Mar 2014 / Staff Governance / 30 April 2014 / Y / 24 Nov 2014 / Staff Governance / 4 Dec 2014
527 (Formerly 1890(Staff Governance) / R King / 10 Mar 2014 / Staff Governance / 30 April 2014 / Y / 24 Nov 2014 / Staff Governance / 4 Dec 2014
523 (Formerly 3177 (Policy & Procedural Updates - HR)) / R King / 10 Mar 2014 / Staff Governance / 30 April 2014 / Y / 24 Nov 2014 / Staff Governance / 4 Dec 2014
521 (Formerly 3035 (Capacity Planning) / H Knox / 10 Mar 2014 / Acute Services Division / 19 Mar 2014 / Y / 15 Sept 2014 / Acute Services Division / 24 Sept 2014
519 (Formerly 3040 (Health, Safety & Fire) / R King / 10 Mar 2014 / Health & Safety Governance / 16 April 2014 / Y / 8 Dec 2014 / Health & Safety Governance / 18 Dec 2014
526 (Formerly 1280 (Legionella) / J Leiper / 10 Mar 2014 / Health & Safety Governance / 16 April 2014 / Y / 8 Dec 2014 / Health & Safety Governance / 18 Dec 2014
517 (Formerly 3037 (Finance) / C Bowring / 17 Mar 2014 / Finance & Resources / 25 Mar 2014 / Y / 22 Sept 2014 / Finance & Resources / 30 Sept 2014
522 (Formerly 2124 (Prescribing & Meds Management) / C Bowring / 17 Mar 2014 / Finance & Resources / 25 Mar 2014 / Y / 22 Sept 2014 / Finance & Resources / 30 Sept 2014
523 (Formerly 3177 (Policy & Procedural Updates - General) / C Bowring / 17 Mar 2014 / Finance & Resources / 30July 2014 / Y / 22 Sept 2014 / Finance & Resources / 30 Sept 2014
516 (Formerly 3042 (Infection Control) / S McLean / 31 Mar 2014 / Clinical Governance / 9 April 2014 / Y / 29 Sept 2014 / Clinical Governance / 8 Oct 2014
520 (Formerly 922 (Child Protection) / S McLean / 31 Mar 2014 / Clinical Governance / 9 April 2014 / Y / 29 Sept 2014 / Clinical Governance / 8 Oct 2014
529 (Formerly 3036 (Information Governance) / E Coyle / 24 Mar 2014 / Clinical Governance / 9 April 2014 / Y / 29 Sept 2014 / Clinical Governance / 8 Oct 2014
523 (Formerly 3177 (Policy & Procedural Updates - Clinical) / S McLean / 17March 2014 / Quality, Safety & Governance (Clinical Governance) / 30 April 2014 / Y / 20 Oct 2014 / Quality, Safety & Governance (Clinical Governance) / 29 Oct 2014
(842) In patient Falls
New: Added to Register July 2014 / M Porter / N/A / N/A / N/A / N/A / 29 September 2014 / Clinical Governance Committee / 8 Oct 2014

* Denotes SMT meeting to which draft paper / verbal report should be submitted preceding relevant Governance Committee

Report to the NHS Fife Audit & Risk Committee on 18 September 2014 on the Corporate Risk Register / V1.0 / 26 August 2014
Pauline Cumming / Page 1 of 6