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Strategic Risk Report

11 September 2014

Haringey CCG Risk Register HARINGEY CCG STRATEGIC OBJECTIVES:

1) To commission high quality, valued and responsive services, working in partnership with the public to make the best use of available resources; 2) To promote wellbeing, reduce health inequalities and improve health outcomes for local people; 3) To improve the health and quality of life for people by commissioning integrated health and social care delivered closer to home.

2 11.9.14

Introduction The Strategic Risk Report (historically known as the Board Assurance Framework) evidences Haringey Clinical Commissioning Group’s control over the delivery of its strategic objectives listed above. This report directly underpins the Annual Governance Statement (AGS) and is the subject of annual enquiry by Internal and External Audit.

Function of the Strategic Risk Report This report is a tool for the Governing Body corporately to assure itself (gain confidence, based on evidence) about successful delivery of the organisation’s strategic objectives. The framework is designed to focus the Governing Body on controlling principal risks threatening the delivery of those objectives. It aligns principal risks, key controls and assurances on controls alongside each objective. Oversight of the management of individual risks is assigned to relevant Governing Body Committees. Where gaps are identified and key controls and assurances are insufficient to reduce the risk of non-delivery of objectives, action plans will be created where appropriate and overseen by the responsible committee. The Senior Management Team and the Audit Committee routinely review all risk on the Risk Register, whereas the Governing Body receives a more high-level Strategic Risk Report, containing risks rated 12 and above. The purpose of the Strategic Risk Report may be summarised as: To provide:

a comprehensive method for the effective and focused management of the principal risks to achieving strategic objectives; and

a basis for the preparation of a fair and representative Annual Governance Statement.

Governing Body responsibility for the Strategic Risk Report

It is the responsibility of the Governing Body as the corporate head of the CCG to: Establish strategic objectives. Identify the principal risks that threaten the achievement of these objectives. Identify and evaluate the design of key controls intended to manage these principal risks. Set out the arrangement for obtaining assurance on the effectiveness of key controls across all areas of principal risk Evaluate the assurance across all areas of principal risk. Identify positive assurances and areas where there are gaps in controls and / or assurances Ensure that plans are put in place to take corrective action where gaps have been identified in relation to principal risks and receive

assurance Maintain dynamic risk management arrangements including, crucially, a well-founded risk register. Open risks and recently closed risks are set out in pages 6-21. Closed risks are detailed in pages 22–39.



3 11.9.14

Strategic Risk Heat Map

Imp

act

5

4

3

2

1

1 2 3 4 5

25

6 9 24

12

14 26

23

10

22



4 11.9.14

Likelihood Strategic Risk Summary – Open Risks

Ref Risk Residual Priority

Key changes since last review

6 There is a risk of the Commissioning Support Unit failing to deliver the Service Prospectus.

9 Progress against the planned action has been updated.

9 There is a risk that the CCG is unable to demonstrate it has delivered its duty under the NHS Constitution to ensure patients “have the right to access services within maximum waiting times”.

9 No significant change since last review.

10 There is a risk of failing to fully integrate all elements of unscheduled care within Haringey.

12 Causes and effects, existing mitigations, assurances and progress on actions have been updated.

12 There is a risk of the CCG being in breach of data handling and personal confidential data in accordance with Information Governance requirements.


14

There is a risk of that the CCG will not be able to achieve planned efficiency savings relating to integrated care and invoice validation, due to the changed legal position concerning the CCG’s and the CSU’s ability to process Personal Confidential Data.

9

No significant change since last review.

22 There is a risk of failing to deliver a balanced Financial Plan in 2014/15.

16

Assurances and planned actions have been updated.

23

There is a risk that the CCG is unable to be assured of the quality of commissioned services delivered within mental health and learning disability (LD) establishment/care agencies, including out of area providers for mental health, LD and frail elderly.

6

Progress against planned actions has been updated.

24 There is a risk of being unable to implement health economy-wide strategic change across Barnet CCG, Enfield CCG, Haringey CCG and BEHMHT.


25

There is a risk of being unable to implement health economy-wide strategic change across Haringey CCG, Islington CCG and Whittington Health.

12

No significant change since last review.



5 11.9.14

26

There is a risk that BEHMHT will fail to deliver the improvement plans in place and the quality and safety of services may deteriorate further.

12

Progress against planned actions has been updated.



6 11.9.14

Risk Ref:

SO: Risk Description Risk Owner

Lead Committee

Cause and Effects Why could this risk occur and what

could be the effects if the risk materialised?

Inherent Risk

Score (Without Controls)

Existing Mitigation / Controls How are we managing this risk? What are the Key Controls in place to prevent this

risk from occurring?

Assurance / Evidence Who / Where can we gain

evidence that these controls are working effectively?

Residual Risk

Score (Current)

Planned Actions: Is the action a Gap in Control (C) or a Gap in Assurance (A)

Progress on Action At what stage are we at with

the current action?

6 1 There is a risk of the Commissioning Support Unit failing to deliver the Service Prospectus due to organisational instability.

Risk Owner

Jill Shattock – Director of Commissioning

(Old Risk 11)

Lead Committee Audit Committee

Causes

Lack of understanding of requirements and CCG needs

Lack of CSU capacity and capability

Poor levels of resilience

Lack of communications and monitoring of SLA

CCGs decommissioning services or parts of services.

Effects

CCG does not have timely, quality data that it can use to make informed decisions.

CCG cannot carry out all contracting requirements as lead commissioner.

Creditors not paid in a timely manner.

Negative stakeholder perception as a result of poor direct third party (CSU) interaction.

Some services will be too small to remain viable to offer to a reduced number of CCGs.

I = 4

L = 4

16

1. Regular informal meetings between the Contracts Director and Chief Officer. The Chief Finance Officer and Director of Commissioning also hold weekly meetings with the Deputy Director of Contracts.

2. Signed and agreed SLA in place with clear product lines and KPIs, monthly review meetings in place.

3. Finance, contracts, quality, performance and analytics teams are on site regularly and there is also increased HR visibility.

4. Quarterly performance review meetings.

1. Improved communications/regular dialogue at senior level.

2. Minutes of review meetings and report from Internal Audit to Audit Committee.

3. Improved day-to-day working relationships.

4. Minutes of meetings.

I = 3

L = 3 9

Action

Ensure CSU delivers all aspects of service offer.

Implement internal auditors recommendations by due dates.

Review and update the Service Level Agreement between the CCG and CSU by both parties to supersede the previous SLA and to cover all 5 CCGs in North Central London. This includes adding:

The total SLA cost of

services in the draft

revised SLA

allocated to the

various service lines

being provided by the

CSU.

Flexibility for removal

of elements of the

service being offered

during the contract

period, including the

cost associated with

the discontinued

service.

The process by

which any risks

impacting the CCG

that emerge at the

CSU in the process if

discharging it duties

Vacancy numbers reducing as staff are appointed.

Key staff members regularly on site.

Open communication.

Project support engaged to review CSU offer and structure across all NCL CCGs.

The CSU Improvement Plan is in development and the Improvement Steering Group, chaired by the Haringey CCG Chief Officer, continues to meet on a fortnightly basis.



7 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

to the CCHs are

flagged up and

reported to the CCG.

Provision allowing

the CCG to cancel

any elements of the

services being

provided if the CSU

is not meeting its

performance

standard.

The committee that discusses monthly performance of the CSU to report to a superior committee, such as the Finance and Performance Committee.

Action owner

Jill Shattock, Director of Commissioning

Implementation date

1.4.14

9 1,2,3 There is a risk that the CCG is unable to demonstrate it has delivered its duty under the NHS Constitution to ensure patients “have the right to access services within maximum waiting times”.

Risk Owner

Causes

Barnet and Chase Farm have been unable to report an accurate RTT position since September 2013 and have not reported any manual commissioner data for several months.

I = 4

L = 4

16

1. Whittington Health has developed the necessary software fixes and is now compliant with national uploads for all three RTT indicators. 2. Barnet and Chase Farm Hospitals were formally acquired by the Royal Free London on 1.7.14. The local 18 week rules to be applied to the new

1. Whittington Health commenced full RTT reporting from end of June and is closely monitoring the impact of this, with further oversight and monitoring by CSU.

2. Post-acquisition the

I = 3

L = 3

9

1. Full implementation of Electronic Patient Records at Whittington Health.

Action owner


Implementation date

TBC

1. CSU to confirm whether the EPR at Whittington Health is fully operational across the Trust.



8 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?


New Performance Risk

(Old Risk NCL 717)

(Old Risk NCL 715)

Lead Committee Finance and Performance Committee

Whittington Health has recently uploaded its first iteration of incomplete pathway and backlog volumes after 8 months of non-reporting.

Poor systems and processes within the provider organisations

Effects

Inefficiency and ineffectiveness and poor experiences and outcomes for patients

Increased risk of clinical harm due to longer waits

Risk of failure of Quality Premium relating to the incomplete pathway standard

Reputational damage to the CCG due to failure to achieve national KPIs (18 weeks/ A&E Performance targets etc) at individual provider and borough level.

RTT administrative software tool has been approved by the RF Trust Board and commissioners. 80,000 pathways will be subject to validation with an expected completion date of end of October 14. The Royal Free has established an internal governance structure around 18 weeks with the programme board chaired by the CEO. NHSE is working closely with commissioners and RF in established the business as usual position.

3. The Director of Commissioning is working with the CSU to ensure robust internal monitoring of BCF data and monitoring the accuracy of reporting for WH.

4. Executive Nurse and Director of Quality and Integrated Governance attends meetings of Whittington Health CQRG, CCG Governing Body, Finance and Performance Committee, Quality Committee and Audit Committee which receive performance data and near-time narrative.

5. Consistent approach to the escalation of performance issues

6. System Resilience Group set up by CCG to oversee the operational planning of wholes systems to balance capacity and demand to delivery both RTT and A&E

Royal Free is being held accountable by NHSE and commissioners for the programme management of 18 weeks. An internal governance structure has been agreed with the Programme Board now led by the RF CEO with representation from the lead CCG. The Trust is expecting to recommence national reporting at the end of October. The RF is now leading on the clinical harm review and has appointed an external chair to oversee process.

3. Both BCF and WH are further reducing backlog over July to September as part of the national programme to reduce backlog and waiting times further to 16 weeks. Progress of this will be monitored weekly by NHSE, the CSU and CCGs.

4. Minutes of meetings.

5. CSU escalation framework in place.

6. Ongoing performance during the winter is monitored through the IPD and other performance reports.

Action owner


2. Finalisation of structured validation process for incomplete pathways, with full reporting by July.

Action owner


Implementation date

30.6.14

3. Alternative providers to Barnet and Chase Farm are being identified where possible, in order to increase capacity.

Action owner


Implementation date

TBC

2. Validation and software fixes complete. Full RTT reporting commenced at the end of June 2014. Provisional commissioner data for HCCG shows a reduction in backlog with the Trust compared to the last reported position in August 2013.

The Royal Free is leading on RTT via its own programme management structure and is working up a trajectory to show when the business as usual position will be achieved.

Business as usual trajectory expected in August 2014 when the next NHSE RTT round table meeting is expected to be scheduled.

Re-commencement of national reporting for BCF expected to be at the end of October 2014.



9 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

performance.

7. CSU SLA review meetings.

7. Minutes of CSU SLA review meetings.

Actions plans provided by underperforming trusts and monitored by CSU team.

10 1,2,3 There is a risk of failing to fully integrate and mobilise all elements of unscheduled care within Haringey.

Risk Owner


(Old Risk NCL 759)


Causes

Poor take up of NHS 111 and GP out of hours services.

No formalised operating model agreed for Urgent Care Centre at NMUH

Overuse of A&E service due to expected increase in urgent care activity over winter

Clinical capacity of Out of Hours provider used inappropriately

No incentives for primary care to address in-hours A&E attendance.

Unforeseen activity flows post- implementation of the BEH Clinical Strategy.

Poor A&E performance

Poor demand and capacity resilience and business continuity planning

Effects

Unforeseen impacts upon A&E

Failure to achieve associated unscheduled

I = 3

L = 5

15

1.Continuation into third year of pilot and commissioning new UCC service at NMH in line with BEH Clinical Strategy

2. 111 Clinical Governance Group established and meeting monthly

3. Transition of the Urgent Care Working Group to a system wide, System Resilience Group, chaired by the CCG, with representation from ECCG, NMH, BEH, Enfield and Haringey Social Services and Public Health, Emergency Planning. The SRG has responsibility for both urgent and planned care, to ensure that elective care is not compromised by surges in urgent care activity.

4. The System Resilience Group has developed an Annual Work Programme to reflect the new and ongoing remit around system wide resilience.

5. The System Resilience Group has developed a Risk Assurance Framework to ensure that organisations have relevant

1. System Resilience Group has oversight of Demand and Capacity planning (and consequent effect on A&E performance) and residual BEH urgent care workstream actions.

2. Engagement with NHS 111 Clinical Governance Group/minutes of Governance Group meetings.

3. The System Resilience Group’s Terms of Reference, Annual Work Programme/Forward Plan and Risk Assurance Framework.

Delivery Plan for winter schemes has been developed to ensure mobilisation and full implementation by agreed dates, including details of plans to monitor spend and performance of each scheme.

4. CCG reviews progress at

I = 3

L = 4

12

Action

Revised version 2 of Urgent Care Centre (UCC) service model agreed. Procurement timescales in place.

Action owner


Implementation date

To be confirmed.

The UCC procurement has concluded with a named preferred provider. Discussion underway around affordability of new system.



10 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

care KPIs

Ineffective and inefficient use of GP capacity

Failure to reduce unwarranted A&E activity

Contract over performance in certain areas

Scrutiny by NHSE/TDA

Damage to CCG reputation

Impact on waiting times for planned treatment

resilience, escalation and business continuity plans in place.

6. Revised Recovery and Improvement Plan for A&E target, resubmitted 29.8.14 for full assurance.

7. Resilience Plan for both Urgent and Planned care resubmitted for full assurance 21.8.14

monthly System Resilience Group meetings.

5. CCG has incorporated in the Annual Work Programme.

6. Revised R&IP Plan

7. Revised Resilience Plan

12 1 There is a risk of the CCG being in breach of data handing and personal confidential data in accordance with Information Governance requirements.

Risk Owner

Jennie Williams – Director of Quality and Integrated Governance.

(Old Risk NCL 760)

Lead Committee Quality Committee

Causes

Lack of suitable IG Controls

Staff unaware of responsibilities

Lack of policy and guidance

No IG Training

Sub Contracted work

Effects

Loss of confidentiality integrity or availability of data

Poor reputation

Ability to deliver business as usual

Fines up to £500,000.

I = 5

L = 3

15

1. Responsibility for oversight of Information Governance has been put in place and a Caldicott Guardian (Head of Quality and Performance) and Senior Information Risk Owner (Executive Nurse and Director of Quality and Integrated Governance) have been appointed.

2. Information Governance Framework, IG Policies and high level plan in place and detailed.

3. Specialist Information Governance support is in place from NEL CSU.

4. Mandatory annual training is an organisational priority and staff are in the process of carrying out their annual online IG Training

5. Secure technical IT solutions to access information securely (Blackberries, memory sticks, iPads, Citrix Remote Access).

6. The CCG is acting in accordance with national guidance and only

1. Executive Nurse and Director of Quality and Integrated Governance and Head of Quality and Performance provide assurance that roles and responsibilities are covered

2. Evidence collated as part of 2013/14 initial CCG IG return. Policies due to be reviewed in 2014.

3 CSU Information Governance Manager provides Quality Committee with quarterly Information Governance Report, including compliance with IG toolkit, issues relating to the review of HCCG systems update on implementation of national guidance.

4. Training records

I = 5

L = 1

5

Action

1. CSU IG manager to lead on development of refreshed IG Action Plan to include on-going communications and awareness surrounding the appropriate use of Personal Confidential Data as a CCG

Action owner

Jennie Williams, Director of Commissioning. Implementation date

Draft Action Plan approved by CCG Quality Committee on 18.6.14. Final Action Plan to be approved by Quality Committee on 20.8.14.

Action

2. NEL CSU to provide more assurance on how to request disposal of IT

1. Action Plan implemented by CSU IG team, with support from CCG IG lead.

SMT receives regular reports from the CSU, including compliance with mandatory training. CCG aiming to achieve 100% compliance by March 2015.

2. CSU has Disposal of Media Policy in place and has signed contract with



11 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

accesses limited Personal Confidential Data where there is a legal basis to do so.

7. Heightened awareness of the appropriate use of Personal Confidential Data.

8. CSU has been granted ASH status until October 2014.

9. Data mapping review carried out in January 2014 to identify all information assets held by the CCG and the flows in and out of the organisation along with the associate controls.

provided by CSU IG Team.

5. Audit carried out by RSM Tenon to cover access controls and network security. CSU has carried out data flow mapping of information security – risks and mitigations are in place.

6. Review against compliance verified via IG Toolkit.

7. CCG achieved 100% compliance for mandatory IG training in 2013-14.

8. CCG receives restricted/weakly pseudonymised data.

9. Report of mapping review produced by CSU IG lead and action plan drawn up to address identified issues.

assets and give assurance that assets are disposed of in a secure confidential manner

Action owner

Jennie Williams, Director of Quality and Integrated Governance.

Implementation Owner:

CSU IT Team.

Implementation date

31.7.14.

ICEX. No destructions have been carried out to date.



12 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

14 1 There is a risk that the CCG will not be able to achieve planned efficiency savings relating to integrated care and invoice validation, due to the changed legal position concerning the CCG’s and the CSU’s ability to process Personal Confidential Data.

Risk Owner

Jennie Williams – Director of Quality and Integrated Governance


Causes

Current confusion over approved information flows from data held at Hospitals that feed into NHS England, CSU and through to CCG

On-going challenges with PCD

Effects

Delays in service delivery

Increase costs

Potential legal implications

Reputational damage

I = 3

L = 4

12

1. CSU Information Governance team, with sufficient experience, to support the CCG by providing alternative methods to enable information to be used that remain within legal requirements.

2. Engagement with NHS England, Health and Social Care Information Centre and national bodies involved in the review of potential flows of personal confidential data to support commissioning

3. There is a section 251 in place for a temporary period (until October 2014) to allow HCCG to mitigate this risk to an extent.

4. CSU has obtained Accredited Safe Haven status for a specified time (until the end of October 2014) which will allow some data to flow. As a result an assurance statement has been signed by the CCG CSU is now working in a Controlled Environment for Finance (CEfF).

5. Fair Processing Notices, setting out to the public how the CCG and the wider NHS use patient information, placed on the CCG website.

1. IG Activity log demonstrates the support the IG Team are providing to services and departments to demonstrate active management of issues and proactive management of potential risks.

2. CSU IG Manager liaises with NHS England on behalf of the CCG.

3. The CSU is now operating as part of a Controlled Environment for Finance to undertake validation.

4. Reviews by HSCIC (Health and Social Care Information Centre) and RSM Tenon on CSU provision, including performance and information governance.

5. Notices placed on the CCG website in April 2014.

I = 3

L = 3

9

Action

1. Implement the Information Governance action plan to achieve level 2 in all IG Toolkit requirements by 31.3.15 (C)

Action owner

Jennie Williams DQIG

Implementation Date

1.4.14

1. A CSU-CCG IG network has been established to provide on-going IG support, including the processing of PCD and learning from data-mapping. The CCG is undertaking required actions to implement IG standards to process PCD where there is a lawful basis to do so. The long-term strategy is for HCCG to work with providers so that they have a consent model in place to cover the data and flows.



13 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

22 1 There is a risk of failing to deliver a balanced Financial Plan in 2014/15.

Risk Owner

David Maloney – Chief Finance Officer

Lead Committee

Finance and Performance Committee

Cause 1. Failure to control acute activity during 2014/15. 2.In-year over-performance which would cause the CCG to over-spend against its overall budget. 3. Failure to deliver 2014/15 QIPP Plan.

Effect Failure to fulfil the CCG’s statutory financial duties.

I = 4

L= 4

16

1.Appropriate financial governance systems in place

2.Timely financial reports from CSU,CCG into Finance and Performance Committee and CCG Governing Body

3. Review of 2014/15 QIPP Plan at QIPP Delivery Group and Finance and Performance Committee meetings.

4. Submission of Financial Plan to NHS England and assurance by NHS England in line with national timetable.

5. 2014/15 budget setting process.

6. Approval of Financial Plan by Finance and Performance Committee and Governing Body.

7. Review and ongoing scrutiny of the CCG’s financial performance by Finance and Performance Committee and Governing Body.

1. Internal Audit reports produced by Internal Audit which cover both financial procedures within the CCG and the CSU.

2. Papers and minutes of Finance and Performance Committee and CCG Governing Body.

3. Papers and minutes of QIPP Delivery Group and Finance and Performance Committee.

4. Financial Plan was submitted to NHS England on 4.4.14. An updated version was submitted to NHS England on 20.6.14.

5. Budget holders have signed off their 2014/15 budgets which were uploaded onto the ledger in early April 2014.

6. The 2014/15 Financial Plan was approved by the Finance and Performance Committee on 20.3.14 and by the Governing Body on 26.3.14.

7. The monthly finance and activity report for Month 4 shows that the CCG was overspent by £1.6m for this

I = 4

L= 4

16

Action

1. Conclude contracting round with providers.

Action owner:


Implementation date:

June 2014.

Action

2. Identification of additional areas for 2014/15 QIPP. Action owner:



Ongoing during 2014/15.

Action

3. The CSU has been requested to undertake a number of actions in relation to the overspend in the CCG’s acute contract. These were set out in the Finance Report presented to both the Finance and Performance Committee

1. Contracts agreed with NMH, Whittington Health, BEH MHT and smaller contracts.

Agreements with UCLH and the RFH/BCF Foundation Trusts are outstanding but are subject to a different timetable.

2. The QIPP Plan for 2014/15 currently stands at £8.9m. Updates regarding the 2014/15 QIPP Plan are a standing item at the QIPP Delivery Group meetings, where the identification of additional opportunities is also discussed on an ongoing basis.



14 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

period. The main cause of the overspend is over-performance in the CCG’s contracts with NMUH, UCLH and Barnet and Chase Farm. There are also financial pressures developing in the Continuing Healthcare and prescribing budgets.

and the Governing Body in July 2014.

Action owner:

Steve Rubery, Contracting Director, NELCSU

Implementation date: September 2015

In addition, an Activity Query Notice (AQN) has been issued to the North Middlesex Hospital. The content of the AQN is being worked through with the Trust via the Contract Management Group.



15 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?



16 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

23 There is a risk that the CCG is unable to be assured of the quality of commissioned services delivered within mental health and learning disability (LD) establishment/care agencies, including out of area providers for mental health, LD and frail elderly.

Risk Owner

Jennie Williams – Executive Nurse and Director of Quality and Integrated Governance

Lead Committee

Quality Committee

Causes

Lack of robust processes in place for evaluating quality

The challenge of other effective communications with other CCGs who have geographical oversight.

Effects

Patients placed in establishments not receiving high quality personalised care.

An increase in single safeguarding alerts or establishment concerns regarding standards of care delivered to adult residents in local registered care homes

An increase in unnecessary acute admissions.

I= 3

L=4

12

1. 1. Attendance at establishment concerns meeting. 2. CHC nurses informally evaluate quality of care providers and escalate any individual safeguarding concerts through local authority safeguarding leads

3. The safeguarding team works closely with the Continuing Health Care (CHC) team and Care Homes team to ensure safeguarding concerns are reported and managed appropriately.

1. 1. Minutes of establishment concerns meeting

2. 3. 2. Single alerts are

documented on Care track (CHC database).

3. Team meeting minutes

I= 2

L=3

6

Action

1. Extend the role of the care homes team manager to develop a model of oversight for all establishments and care agencies.

Owner

Cassie Williams, Head of Quality and Performance

Implementation date

September 2014

Action

2. To integrate a quality review of establishments / agencies as part of the regular case load review.

Owner


Implementation date

June 2014

Action

3. Develop a robust system for feedback and escalation of concerns within the CCG and to other CCGs/LA with geographical oversight.

Owner


1. The new Care Home and Care Agency Team Manager is now in post (since 5.8.14) and is in the process of developing a project to improve quality oversight of mental health and LD providers. The project plan aims to be developed by October 2014.

2. The Continuing Healthcare review documentation was finalised and agreed in June 2014 and is now being implemented. The Lead Nurse is now reviewing effectiveness as part of audit completion. This is due to be completed by the end of July.

3. Relationships currently being developed. A new weekly CCG meeting between the care homes team, CHC and Safeguarding is now in place. A clear process will be documented and agreed with partner agencies by September 2014.



17 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

Implementation date

September 2014



18 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

24 1,2,3 There is a risk of being unable to implement health economy-wide strategic change across Barnet CCG, Enfield CCG, Haringey CCG and BEHMHT.

Risk Owner

Jill Shattock - Director of Commissioning

(Old Risk 2)


Causes

Failure to secure sufficient engagement and collaboration across the multiple organisations.

Failure to negotiate QIPP scheme requirements into contracts.

Effects

Impact on the future viability of the Trust and progress towards Foundation Trust status.

Patient experience and service quality will be detrimentally affected.

Ineffective value for money from services commissioned.

I = 3

L = 4

12

1. Monthly Joint organisation Transformation Board.

2. Joint workstreams to progress transformation projects and pathways.

3.Clinical workshops in place as necessary.

4. Tri-Borough Commissioning forum in place for BEH MHT, attended by Director of Commissioning.

1.Minutes of monthly meetings.

2. Workstream papers

3. Evidence of clinical workshops

4. Minutes of forum meetings.

I = 3

L = 4

12

Action

Progress through commissioning and Transformation Boards.

Action owner

Jill Shattock/Sarah Price

Implementation date

Ongoing

Joint Groups now in place, including representation from local authorities.

Independent review produced by Mental Health Strategies Ltd which recommended eight areas of focus which have now been adopted by all three CCGs and the Trust. These are now being progressed via various forums as appropriate.



19 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

25 1,2,3 There is a risk of being unable to implement health economy-wide strategic change across Haringey CCG, Islington CCG and Whittington Health.

Risk Owner


(Old Risk 2)


Causes

Failure to secure sufficient engagement and collaboration across the multiple organisations


Effects

Impact on the future viability of the Trust and progress towards Foundation Trust status.

Patient experience and service quality will be detrimentally affected.

Ineffective value for money from commissioned services.

I = 3

L = 4

12

1. Monthly Joint Transformation Board.



4. Transformation Director appointed to oversee and provide additional capacity.

1. Minutes of monthly meetings.

2. Workstream papers.

3. Evidence of clinical workshops.

4. Minutes of Monthly Joint Transformation Board which Transformation Director attends.

I = 3

L = 4

12

Action

Progress through Transformation Boards

Action owner


Implementation date

Ongoing

Joint Group now in place.



20 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

26 1,2 There is a risk that BEHMHT will fail to deliver the required improvements in the quality and safety of services.

(Background: During 2013/14 the Care Quality Commission (CQC) found Barnet Enfield and Haringey Crisis Resolution and Home Treatment Teams to be non-compliant in respect of outcomes 4, 9, 13, 14, 16, and 21 and the St Ann's Hospital site to be non-compliant in respect of outcome 4. Both services have since been re inspected by the CQC and found to be compliant.

Risk Owner

Jennie Williams – Executive Nurse and Director of Quality and Integrated Governance

Lead Committee

Quality Committee

Causes

Inability to provide consistently high quality services

Effect

There will be a further deterioration in the quality and safety of services.

BEHMHT will be deemed not to meet regulatory standards in respect of CQC outcomes.

I = 3

L = 4

12

1. Following a review undertaken by the Trust Development Authority (TDA) in 2013 a comprehensive service improvement plan has been refreshed and agreed by the TDA local commissioners and NHS England.

2. The delivery of the quality delivery plan is overseen by the Clinical Quality Review Group (CQRG).

3. Monitoring of the Trust’s performance against key patient safety and experience metrics is undertaken by CQRG.

4. A 2014/15 programme of ‘walk the pathway’ visits has been developed by Enfield CCG to enable local CCG clinicians, commissioners and stakeholders to seek further assurance on the quality and safety of the services.

1. The BEHMHT quality delivery plan (2014)

2. CQRG papers and minutes

3. CQRG minutes provide evidence of review of the Trust’s quality and safety dashboard and specific focus on safeguarding, patient complaints and serious incidents.

4. The outcome of each visit and agreed actions will be evident in CQRG minutes

I = 3

L = 4

12

Action

1. To provide Haringey CCG Quality Committee with updates on delivery of the plan and ensure the CCG Chief Officer and Chair are informed of emerging or reported concerns relating to quality and safety.

Action Owner

Jennie Williams

Implementation date

From June 2014

Action

2. To ensure the Integrated Performance Dashboard (IPD) provides sufficient data and narrative to ensure CCG Governing Body members are informed on key issues relating to quality and safety.

Action Owner

Jennie Williams

Implementation date

From month 3 of the IPD

Action

3. CCGs to request to co-ordinate a ‘round table’ meeting to review the Trust’s progress in delivery of service improvements.

2.Cassie Williams has handed performance reporting over to the new Head of Performance (Dee Parker), the Assistant Director – Mental Health Commissioning and CSU colleagues. Further work is needed to ensure that community data is included as part of the IPD. This work will be led by Dee Parker.

3. To determine whether escalation to full risk summit is required, an extended Round Table meeting with BEH MHT is taking place on 3.9.14. Representatives from the



21 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

Action Owner

Jennie Williams

Implementation date

Within 4 weeks from date of NHSE assurance meeting held on 5.6.14.

TDA and NHS England Specialised Commissioning now attend the monthly Clinical Quality Review Group (CQRG) meetings. Enfield CCG, as lead commissioner, continues to ensure enhanced monitoring of quality and safety via the CQRG.



22 11.9.14

Strategic Risk Summary – Closed Risks

Ref Closed Risk Reason for closure

1 There is a risk that systems and processes within Continuing Health Care (CHC) are not fit for purpose.

RISK NOW CLOSED as the team structure has been filled and is operating as planned. (14.5.14)

2 There is a risk of being unable to implement health economy wide strategies across Haringey, NMH and Enfield CCG

RISK NOW CLOSED and replaced by two organisation-specific risks – Risks 24 and 25.

3 There is a risk of failing to effectively manage the process for handling retrospective claims for care costs.

RISK NOW CLOSED. Documentation is now in place for all closed cases. The small number of cases received from other boroughs will be dealt with in line with usual procedures. (13.6.14)

4 There is a risk of the CCG failing to achieve its financial targets in 2013/14. RISK NOW CLOSED as the CCG submitted its draft annual accounts to external audit/NHS England on 23.4.14 in accordance with the deadline, showing a surplus of £74,000. (14.5.14)

5 There is a risk of the CCG failing to deliver its agreed QIPP plan. RISK NOW CLOSED as the CCG achieved its 2013/14 QIPP Plan and

overall 2013/14 Financial Plan (see Risk 4). (14.5.14)

7 There is a risk of the CCG being unable to fulfil its responsibilities to manage Healthcare Associated Infections (HCAIs) among the local population.

RISK NOW CLOSED as the Head of Quality and Performance has now received handover on management of infection control and the Lead Nurse, Quality has been recruited and is in post.

8 There is a risk that financial uncertainty regarding specialist commissioning funding (13/14) might lead to the CCG having a large financial deficit at year-end.

RISK NOW CLOSED as the CCG received £5m from NHS England as a result of the third budget adjustment, leaving a £2m gap, and there are no further additional mitigations.

11 There is a risk of the CCG being unable to achieve the Better Payment Practice Code.

RISK NOW CLOSED due to the now underlying low level of risk.

13

There is a risk of Personal Confidential Data held on invoices for certain services may be placed on the organisations' invoices that are processed and in turn on the ledger.

RISK NOW CLOSED as it has been fully mitigated.



23 11.9.14

15 There is a risk of that alerts received in relation to standards of care in nursing / care homes and capacity issues at Borough level could lead to safety / safeguarding concerns for adult resident patients.

RISK NOW CLOSED and incorporated into Risk 16 (subsequently closed).

16 There is a risk of being unable to determine quality within commissioned nursing homes in the borough of Haringey.

RISK NOW CLOSED as it has been fully mitigated.

17

With the strategic shift from secondary to primary and community care, there is a risk that the CCG is moving from an environment where it has robust assurance processes on quality to one where it has less assurance.

RISK NOW CLOSED as superseded by Risk 20 (subsequently closed).

18 There is a risk that the quality of activity information received from UCLH is such that the CCG is not able to use it to enable it to monitor performance against the contract.

RISK NOW CLOSED as year-end position on the UCLH contract was in

line with the forecast at Month 11.

19 There is a risk of failing to fully implement and integrate the BEH Clinical Strategy, thereby failing to ensure that changes become “business as usual” as planned.

RISK NOW CLOSED as urgent care element of risk to be addressed under Risk 10 (subsequently closed).

20 There is a risk of that the strategic shift from secondary to primary and

community care could lead to reduced quality assurance.

RISK NOW CLOSED as actions 1 and 2 were included in risk 16 (subsequently closed). Action 3 is complete and can be closed as shown in risk 7 (closed).

21 There is a risk that the full scope of the palliative care service cannot be delivered and service offered is restricted.

RISK NOW CLOSED as Locum Consultant is in post and nursing vacancies have been filled. (13.6.14)



24 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

1 1,2 There is a risk that systems and processes within Continuing Health Care (CHC) are not fit for purpose.

Risk Owner


(Old Risk 1) Lead Committee Audit Committee

Risk now CLOSED.

Causes

Reviews of on-going operational policies and improvements not carried out

Lack of key staff / resources

Lack of reporting and monitoring of performance

Effects

Lack of governance and failure to comply with the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care November 2012 (revised)

Delivery of the CHC QIPP

Patient experience

I = 4

L = 5

20

1. External support secured to provide external review and advice as to on-going operational issues policies and improvements, including

Team roles and functions review, high cost placement efficiency review and policy updating.

2. Improvement of process for adding any care costs onto the system to ensure consistently tight controls on any new funding added to the system.

3. Existing database cleansing and updating.

1. Monthly Programme Management Board to oversee improvement Programme, chaired by Chief Officer.

2. Two weekly Project Group to support Programme Board, chaired by Director of Commissioning.

3. Training for Caretrack system taken place.

Action

Updated systems and processes to be in place and operational.

Action owner

Jill Shattock

Implementation date

1.9.13

Diagnostic phase now complete and the majority of recommendations have now been implemented.

Team structure reviewed, team leader appointed and team transferred to line management within the Quality and Integrated Governance directorate.

Tri-organisation Task and Finish group convened to review and finalise section 117 policy and procedures. Membership consists of CCG, Haringey Council and BEHMHT. Standard operating policies for clinical assessor team and commissioning/ placement team being finalised.

Placement efficiency project progressing.

The Internal Audit report (September 2013) provided reasonable assurance that the controls in place manage this risk are suitably designed, consistently applied and effective. Action is being taken to address the recommendations in the report.

New team structure now



25 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

filled and operating as planned.

Risk now CLOSED.

2 1,2,3 There is a risk of being unable to implement health economy wide strategies across Haringey CCG, Enfield CCG and provider organisations (NMUH, Whittington Health and BEHMHT

Risk Owner


(Old Risk 4)


Causes

Failure to secure sufficient engagement and collaboration across the multiple organisations


Effects

Impact on the underlying run rate in 13/14 and beyond

Patient experience

Ineffective value for money initiatives

I = 3

L = 5

15

1. Monthly Joint QIPP and Transformation Boards



4. Tri-Borough Commissioning forum in place for BEH MHT, attended by Director of Commissioning.

1.Minutes of monthly meetings.

2. Workstream papers

3. Evidence of clinical workshops

4. Minutes of forum meetings.

I = 3

L = 4

12

Action

Progress through QIPP and Transformation Boards.

Action owner


Implementation date

Ongoing

Joint Groups now in place for three main Trusts – NMUH, Whittington Health and BEH-MHT.

Risk now CLOSED and replaced by two organisation-specific risks – Risks 24 and 25.

3 1 There is a risk of failing to effectively manage the process associated with handling retrospective claims for care costs.

Risk Owner

Jill Shattock - Director of

Causes

Lack of dedicated resource to review existing open claims

Unknown monetary impact

Deadline for resolving claims is 31.3.14

I = 4

L = 4

16

1.Additional capacity has been secured for reviews in CHC Team, including Nurse Assessor

2. Regular reports to CCG GB with updates on progress.

3. Additional panels arranged to review cases.

1.Establishment of Team verified by HR

2. CCG GB reports, detailing progress against outstanding actions and minutes of GB meetings.

I = 2

L = 2

4

Action

All reviews to be completed by 31.3.14 and outcomes enacted.

Action owner

All cases now reviewed - 6 cases agreed as being CHC on retrospective review. Maximum financial exposure is £350,000.

Finalisation of all documentation to support



26 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

Commissioning

(Old Risk 7)

Lead Committee Audit Committee

RISK NOW CLOSED.

Effects

Financial impacts upon CCG budget for the future

Reputational damage

Increased legal costs

3. Director of Commissioning provides weekly status reports to Senior Management Team.


Implementation date

31.3.14

all cases in case of challenge continues during April.

Finalisation of process to access funds for 2014/15 still outstanding as this is now held by NHS England.

Documentation is now in place for all closed cases. The small number of cases received from other boroughs will be dealt with in line with usual procedures.

4 1,3 There is a risk of the CCG failing to achieve its financial targets in 2013/14.

(The CCG is currently forecasting a £7m year-end deficit. This is a direct result of the Specialised Commissioning Risk identified in Risk 8 below).

Risk Owner

David Maloney -

(Old Risk 8)

(Old Risk NCL 783)

Causes

Lack of adequate budgeting and financial planning

Poor financial controls

Breaches in procurement rules

National/government targets and initiatives distract the CCG from delivery and draw on resources.

Poorly constructed contractual agreements with service providers.

Poor CSU financial administration.

Extreme events exceeding expectations i.e. pandemic, weather.

I = 4

L = 4

16

1.Appropriate financial governance systems in place

2.Timely financial reports from CSU,CCG into Finance and Performance Committee and CCG Governing Body

3.CCG 13/14 Financial Plan agreed with NHS England

4.Improved financial reporting processes in place

1. Internal Audit reports produced by Internal Audit which cover both financial procedures within the CCG and the CSU.

2. Papers and minutes of Finance and Performance Committee and CCG Governing Body

3. NHS England confirmation of approval of 13/14 Financial Plan.

4. Ernst & Young undertaken work on improving processes within

Action

Obtain update from CSU for 13/14 SLAs, with particular regards to the SLA with UCLH and RFH.

Action owner David Maloney, CFO

Implementation date

Mid-November 2013.

The CCG reported to the Finance and Performance Committee on 20.3.14 and the Governing Body on 26.3.14 that it is now on target to break even. This forecast is based on an assessment of the financial risks for the remainder of the year.

At M11 the CCG is forecasting a break-even position. Acute over-spend has stabilised and in light of this, the CCG has released reserves. However, risks remain in respect of Public Health services and outstanding challenges



27 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?


The CCG submitted its draft annual accounts to the external audit/NHS England on 23.4.14 in accordance with the deadline. These showed a surplus of £74,000. The draft accounts are subject to external audit and be reviewed by the Audit Committee on 28.5.14.

Risk now CLOSED.

Substantial fraud or sustained fraudulent activity.

Failure to develop and deliver Quality, Innovation, Productivity, Prevention (QIPP) schemes

Effects

Compensating service cuts may be required.

Reputation damage.

Potential intervention from the NHS England - removal of commissioning power from the CCG.

CCG administration/takeover.

the CSU.

which are largely at UCLH and Bart’s Hospital.

5 1,2,3 There is a risk of failing to deliver the CCG's agreed QIPP plan.

Risk Owner


(Old Risk 10)


RISK NOW CLOSED as the CCG achieved its 2013/14 QIPP Plan and overall 2013/14 Financial

Causes

Lack of up to date financial and performance data reviewed at key meetings

Lack of key staff and resources

Lack of a QIPP structure

QIPP plans not supported by others

Effects

CCG will not achieve future financial plans

Negative perception amongst other commissioners and providers

I = 3

L = 4

12

1. Local QIPP delivery group to oversee the 13/14 QIPP plan.

2. NHS England Performance Review meetings take place on a regular basis.

3. Production of monthly budget statements and monthly QIPP performance reports.

4.Discussion with account managers regarding in-year SLA performance

5. Finance reports (including acute/non-acute SLA positions), scrutiny and review by CCG Finance and Performance Committee (monthly) and Governing Body (bi-monthly).

1. Reports and minutes of QIPP Delivery Group and Finance and Performance Committee.

2. Minutes of monthly Performance Review meetings.

3. Recipients of monthly financial reporting.

4. QIPP Delivery Group receives regular reports setting out QIPP delivery. Where risks to delivery are highlighted, schemes are the focus of subsequent meetings.

Action

1. Interim QIPP Director undertaking due diligence to assess accuracy of QIPP reporting.


Implementation Owner: CSU

Implementation date

End of October 2013.

Action

2. QIPP Delivery Group to receive regular updates from project leads –

1. The QIPP Delivery Group meets fortnightly and progress on the delivery of QIPP plans is regularly monitored. An update on the QIPP Delivery Group is a standing item at the Finance and Performance Committee.

2. Regular updates taking place as appropriate. The CCG is still on target to achieve its QIPP plan as at



28 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

Plan (see Risk 4).

6. Monthly report produced showing QIPP financial performance.

7. Recruitment of two permanent QIPP project managers.

5. Reports and minutes of Finance and Performance Committee and Governing Body meetings.

6. Internal Audit report to Audit Committee on 1.7.13.

7. QIPP project managers recruited and in post – September 2013.

specifically where projects have blockages or slippage.


Implementation Owner: All project leads

Implementation date

22.8.13

M11.

An updated report was presented at the Finance and Performance Committee meeting on 20.3.14 setting out the delivery of the 2013/14 QIPP Plan. This showed that the CCG is on target to achieve its £13m QIPP target.

7 1,2 There is a risk of the CCG being unable to fulfil its responsibilities to manage Healthcare Associated Infections (HCAIs) among the local population

Risk Owner


(Old Risk 13)


RISK CLOSED

Causes

Lack of a designated infection control resource

Effects

Patient Experience

Reputational damage

Performance issues

Intervention

I = 3

L = 3

9

1. Director of Quality and Integrated Governance (DQIG) oversees the role and wherever necessary co-ordinate post-infection reviews (PIRs) in accordance with Dept of Health guidance (NHSCB Planning Guidance (2013). CCG Care Homes Nurse will contribute to PIRs if a case originates in a care home.

2. DQIG receiving Public Health England (PHE) automated alerts until further notice.

3. Haringey CCG is recruiting a lead nurse for quality to lead on harm free care (including HCAI.

4. DQIG has access to specialist advice via NHS England (London) Infection Control lead

1.Both local acute trusts are satisfied that DQIG can be contacted promptly for all agreed cases

2. All alerts acted on in timely fashion.

3. DQIG has developed JD and Person Specification for Lead Nurse Quality. This post will provide support to Director of Public Health regarding arbitration cases.

4. DQIG continues to be in regular contact with NHSE lead for HCAI

I = 1

L = 1

1

Action

1. Head of Quality and Performance to receive handover on management of infection control as part of induction. Acute Trusts to be informed of first point of contact. (C)

Action owner


Implementation date

21/8/13

2. Recruit to Lead Nurse Quality which sets out arrangements for supporting arbitration process. (C)

Action owner

Cassie Williams – Head of Quality and Performance

1. This has now been completed. The risk is therefore CLOSED.

2. Quality Assurance Nurse has now started in post and is actively engaging with Trusts around HCIAs.



29 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

Implementation date

2.9.13

3. DQIG to continue brief AO on performance of HCAI at each 1-1 (A)

Action owner


Implementation date

Commencing w/c 19.8.13.

3. Ongoing.

8 1,2,3 There is a risk of financial uncertainty regarding specialist commissioning funding (13/14)

Risk Owner

David Maloney -

(Old Risk 14)


Causes

Lack of clarity regarding specialist commissioning split within London health economy

Lack of financial and activity information

Effects

CCG has a large deficit at the end of the 13/14 financial year.

Compensating service cuts may be required.

Reputation damage.

CCG administration/takeover.

At Month 6 NHS England actioned a transfer in funding from the CCG to NHS England which has created a £7m financial risk for the CCG. This risk is being reported in the CCG’s Month 8 financial

I = 4

L = 4

16

1. Agreement of process to manage specialist commissioning during 1314 by NHS England and CCGs.

2. Technical finance group set up - contains representatives from NHS England and CCGs.

3. CCG Chief Officers have written to NHS England raising concerns regarding the proposed process.

4. Chief Finance Officer is NCL representative of the Technical Group which monitors the performance of activity during 2013/14.

1.Agreement of progress with both NHSE and CCGs

2. Chair of Technical Finance Group is shared between CCGs and NHSE.

3.CCG Chief Officer oversees communications with NHS England

4. Reports provided at Technical Group meetings.

I = 3

L = 5

15

Action

Exercise at month 6 to reconcile budget changes to activity levels.

Action owner

David Maloney, CFO

Implementation date

1.9.13

The CCG received £5m from NHS England as a result of the third budget adjustment, leaving a £2m gap. As there will be no further adjustments, this risk is now CLOSED.



30 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

position and has been communicated to NHS England. It is understood that a third adjustment will be made to CCG budgets which will be based upon the reconciliation from the Specialised Commissioning Technical Group. This has not been factored into the CCG’s financial position. The CCG had an assurance meeting with NHS England at the end of October 2013 where this was discussed.

11 1 There is a risk of being unable to achieve the Better Payment Practice Code.

Risk Owner

David Maloney -

(Old Risk NCL 584)


Causes

CSU lack of capacity and capability to deliver the specified service to the appropriate timescales

Effects

Failure to pay creditors in a timely and reliable manner.

Negative creditor and wider stakeholder perception

Potential for providers to withdraw service provision

Patient care is interrupted if failure to pay is sustained

I = 3

L = 4

12

1.Daily review of Agresso to monitor payments due

2.All appropriate staff trained on Agresso to ensure any queries quickly identified and reported

3. 48 hour turnaround from invoice arrival to budget holders Agresso

4. System has built in mechanism to alert unpaid, unauthorised invoices to budget holder.

5.Reporting of BPPC performance to Governing Body and Finance and Performance Committee.

1.Management Team involved in daily reviews

2.Training records held with HR

3.Testing of the system

4.Testing of the system

5. Minutes of Governing Body and Finance and Performance Committee meetings.

I = 2

L = 2

4

Action

1. To ensure that the CCG is able to achieve the Better Payments Practice Code.

Action owner

David Maloney, CFO.


Implementation date

1.7.13

Action

2. To ensure that applicable invoices are backed up by a purchase order.

Action owner

David Maloney, CFO.

1. Communications received from CSU regarding improving the performance of invoice payments.

2. Training sessions being run for staff. Communication has been sent out to staff highlighting that invoices will no longer be paid without a corresponding purchase order and this process is



31 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?


Implementation date

1.9.13

now firmly embedded among staff. Since July 2013 there has been a significant improvement in the percentage of invoices paid within target timescales.

This risk has been mitigated and is therefore CLOSED.



32 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

13 1 There is a risk of Personal Confidential Data held on invoices for certain services being placed on the organisations' invoices that are processed and in turn on the financial ledger.

Risk Owner


(Old Risk NCL 410)


Cause

Lack of suitable IG Controls

Staff unaware of responsibilities

Lack of policy and guidance

Effects

I = 2

L = 3

6

1.Staff aware of processes to seek consent where possible to process this information in CHC and IFR cases.

2. Providers are encouraged to minimise data shared to enable reconciliation but not identification by wider organisation.

3. Minimal access to the full ledger – only key trained staff.

4. Training for all staff on their responsibilities carried out.

5. Contract with NHS SBS to minimise coding and personal confidential data on invoices.

6. Requests made under the Freedom of Information Act would be reviewed and Personal Confidential Data redacted.

1. Verified through review and testing.

2.Management verification.

3.Security controls managed by System Administrator.

4.Testing records verified by CCG Lead.

5.Contract managed and monitored by NHS England.

6.All requests made under FOI recorded and reviewed by CSU FOI team.

I = 2

L = 2

4

Action

1. Work with SBS and providers to limit inclusion of PID.

Action owner

Chief Finance Officer.

Implementation owner:

Harry Turner/All budget holders.

Implementation date

Ongoing.

2. Review historic/ retrospective invoices.

Action owner

Chief Finance Officer.

Implementation owner:

All budget holders.

Implementation date

Ongoing

1. SBS have reviewed their processes.

Guidance now available from CSU on what to do if an invoice is received with PCD.

Where PCD is received, the sender will be informed that PCD must not be put on invoices and invoices will need to be reissued.

2. Section 251 has been approved to support invoice validation (within controls) until 31 Oct 2014.

This risk has been mitigated and is therefore now CLOSED.



33 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

15 There is a risk that alerts received in relation to standards of care in nursing / care homes in particular Barnet, Enfield and Haringey and capacity issues at Borough level could lead to safety / safeguarding concerns for adult resident patients.

(Old Risk NCL 660)

(Risk closed and incorporated into Risk 16)



34 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

16 1,2,3 There is a risk that the CCG is unable to be assured of the quality of service delivered in commissioned nursing homes in the borough of Haringey.

Risk Owner


(Old Risk NCL 606 updated to reflect current risk )


Causes

Lack of cohesive approach to

measuring and monitoring

quality in care homes.

Effects

Patients placed in Haringey nursing homes not receiving high quality personalised care.

An increase in single safeguarding alerts or establishment concerns regarding standards of care delivered to adult residents in local registered care homes

An increase in unnecessary acute admissions.

I = 3

L = 4 12

1. The current Care homes lead nurse has embedded a robust system for visits to quality assure local registered nursing homes. 2. The safeguarding team works closely with the Continuing Health Care (CHC) team and Care Homes team to ensure safeguarding concerns are reported and managed appropriately. 3. The Assistant Director of Safeguarding and Designate Nurse for Child Safeguarding provides operational support and clinical advice

1. The Care Homes Team escalates all concerns relating to quality and safety in timely fashion.

2. HCCG Safeguarding policy (2013) operational.

Joint policy for establishment concern (2013) is embedded.

Executive Nurse and DQIG is briefed on all safeguarding issues and ensures Chief Officer is kept informed.

3. Monthly updates provided to Quality Committee by Safeguarding team.

I = 2

L = 2 4

Action

1. To complete and implement a revised focus for Care Homes project.

Action owner

Cassie Williams, Head of Quality and Performance.

Implementation date 1.11.13 - delayed until launch events completed which took place in December 2013

Action

2. The Continuing Health Care nurse team to transfer into the Quality and Integrated Governance Directorate

3. There is a need to ensure all staff are compliant with the safeguarding policy and procedures.

Action owner Cassie Williams, Head of Quality and Performance.

1. “Quality Matters in Care Homes” programme is embedded. The programme applies rigour to the review and reporting of quality and safety. The first report was presented to the Insight and Learning Group and will be submitted to Quality Committee in March 2014 and continue thereafter on a quarterly basis. The QIPP Delivery Group will receive progress reports on KPIs related to reduction of avoidable admissions.

2. The CHC nurse team is managed within the Quality and Integrated Governance directorate. Regular meetings taking place between safeguarding CHC and care homes team to ensure close working.

3. The Safeguarding, Care Homes and Continuing Health Care teams will be compliant with adult safeguarding training including (Dols and MCA), by the end of Q4. Risk now fully mitigated and therefore CLOSED.



35 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

17 With the strategic shift from secondary to primary and community care, there is a risk that we are moving from an environment where we have robust assurance processes on quality to one where we have less assurance.

Risk Owner


(Old Risk NCL 640)

Risk closed and superseded by risk 20.



36 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

18 1 There is a risk that the quality of activity information received from UCLH is such that the CCG is not able to use it to enable it to monitor performance against the contract.

Risk Owner

David Maloney, Chief Finance Officer.


Risk now CLOSED as year-end position on the UCLH contract was in line with the forecast at Month 11. The figures are now subject to external audit.

Causes

Poor quality data submitted to the CSU by UCLH.

Effects

Inability of the CCG to properly reflect the financial performance of the ULCH contract for 2013/14. Financial cost pressure reported by CCG is activity far beyond the budget that the CCG has set.

I = 4

L = 3

12

1. CSU on behalf of CCG are communicating with UCLH to get to the position that the Trust can submit accurate information.

2. CSU contract lead is in post.

3. CSU Director of Finance now playing a greater role in the UCLH contract.

4. CSU agreeing contract with UCLH for 2013/14.

1. Regular reports on the UCLH position are taken to CCG Chief Officers meetings and contract performance meetings, as well as it being a standing item at meetings of the Finance and Performance Committee. Furthermore, as part of the month end financial reporting process, an assessment is made by the CSU of the financial risk for each trust. However, at present these provide limited assurance as actions being taken are not impacting on the financial position.

2. More rigorous approach to contract management.

3. CSU Director of Finance attending Finance and Performance Committee Meeting on 20.12.13.

4. Contract agreed in January 2014.

Action

1. Joint working with UCLH to agree correct level of activity.

Action owner

David Maloney, CFO

Implementation Owner:

Michelle Powell, CSU

Implementation date

Month 8.

The forecast out-turn at M11 was £3.5m. This was a slight improvement on the previous position.

In addition, the CSU Director of Finance attended the Finance and Performance Committee meeting on 20.12.13 and 23.1.14 and confirmed that potentially £0.9m could be removed from the forecast UCLH out-turn.

The UCLH position was discussed in detail at the Finance and Performance Committee meeting on 20.3.2.14. The CCG has requested an update from the CSU in respect of outstanding challenges - in particular, clarity around those challenges which are likely to remain unresolved at year-end.



37 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

19 1,2 There is a risk of failing to fully implement and integrate the BEH Clinical Strategy and not ensuring that changes become “business as usual” as planned.

Risk Owner

Sarah Price – Chief Officer. Lead Committee Finance and Performance

Causes:

Unforeseen activity volumes

Workforce issues

Delays in or disruption to building work

Effects

Impact on quality and safety in either of the local acute providers

Increased financial risk as a result of unused capacity or over-performance/ activity pressures elsewhere

Impact on performance attainment.

I = 5

L =3

15

1. Contingency plans in place against key programme risks which are monitored regularly. All workstreams have specific role to manage quality and safety during transition.

2. Workforce group in place, meeting monthly. Recruitment tracker in place and being monitored on a regular basis, including at the BEH Programme Board and NCL Clinical Cabinet.

3. Risk share agreement across North Central London CCGs agreed by all five Governing Bodies to support transitional funding. (Haringey GB approval on 25.7.13).

1. Programme risk register reviewed monthly through NCL Clinical Cabinet and BEH Programme Board.

External assurance by NHS England continues to monitor and assure key programme risks.

2. Final BEH Programme Board to close programme and establish handover of key workstreams.

3. Minutes of Workforce group, BEH Programme Board and NCL Clinical Cabinet.

Active engagement of Chairs/Chief Officers/senior staff in BEH Clinical Strategy governance structure.

I = 1

L =

1

Action

1. Continue to monitor progress against implementation plans and proactively address risks and issues.

Urgent Care Working Group now monitoring ongoing demand and capacity and consequent impact on A&E performance.

Action owner

Siobhan Harrington, Programme Director, Barnet, Enfield and Haringey Clinical Strategy Programme

Jill Shattock, Director of Commissioning.

Implementation date

1.2.14

Action

2. CCG risk register will be updated following programme close on 21.2.14. Ownership of the residual risks will be transferred to the individual CCGs as appropriate.

Action owner

Siobhan Harrington, Programme Director, Barnet, Enfield and

The BEH Clinical Strategy Programme has now formally closed and residual the residual risk to monitor ongoing demand and capacity has passed to the Urgent Care Working Group – see Risk 10.

This risk is therefore CLOSED



38 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

Haringey Clinical Strategy Programme

Jill Shattock, Director of Commissioning.

Implementation date

1.3.14

20 1 There is a risk around moving from an environment where we have robust assurance processes on quality to one where we have less assurance.

Risk Owner


Lead Committee

Quality Committee

Causes

Strategic shift from secondary to primary and community care,

Effects

Unforeseen impact on quality and safety to patients

Reputational damage to CCG and providers

Failure to achieve national Q&S KPIs for example HCAI and reduction of harm

I = 3

L = 3

9

CQRG monthly meetings in place for acute providers and 111 service

Recognition that the CCG does not have a systematic approach to quality assurance of smaller providers has led to the Head of Quality asking the care homes team to undertake a baseline review of registered nursing homes.

External clinical governance review by auditors

Quality report to the Quality Committee (QC) and receipt of minutes of CQRGs for key acute providers

Senior Management Team (SMT) receives a monthly briefing paper setting out how CCG will receive assurance on the quality and safety of care provided by local registered nursing homes.

External clinical governance review report

I = 3

L = 3

9

Action 1. Determine CCG responsibilities for quality and safety in local residential homes (A)

Action Owner Jennie Williams, Director of Quality and Integrated Governance

Implementation date By end of November 2013.

Action 2. Lack of clarity regarding role and responsibilities of CCG care home team in seeking assurance re Q&S from smaller providers and framework.(A)


Implementation date By end of November 2013.

1 and 2. Head of Quality and Performance has undertaken a review of the Care Homes team with focus development of framework (including KPIs) for use with smaller providers based on the existing CQRG model. The programme is now implemented. The first report has been presented to the Insight and Learning Group and will form part of a suite of regular reports to Quality Committee.

3. As set out in Risk 7, a Quality Assurance Nurse is in post and has started leading on the monitoring of HCAI and pressure ulcer work. The post holder has started to focus on leading a programme of work to reduce community acquired pressures and healthcare acquired infections in community settings.



39 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

Action 3. Lack of robust approach to performance managing smaller providers on management of infection control and pressure ulcers


Implementation date By end of December 2013.

This risk is now CLOSED as actions 1 and 2 are included in risk 16. Action 3 is complete and can be closed as shown in risk 7 above.



40 11.9.14

Risk Ref:


Lead Committee



Inherent Risk






Residual Risk

Score (Current)



the current action?

21 3 There is a risk that the full scope of the palliative care service cannot be delivered and service offered is restricted.

Consultant locum post will not be filled in full from April 2014.

Risk Owner


Lead Committee

Quality Committee

RISK NOW CLOSED as Locum Consultant is in post and nursing vacancies have been filled.

Cause Provider staffing shortages: two recent retirements within the palliative care team; long term sick leave within the team and Divisional Head of Nursing post vacant.

Winter Pressure Response (to offer 7 day a week service) is not delivered.

Effect

Reduced staff capacity may limit the level of provision until vacancies are filled. Increased pressure on service due to staff sickness and compassionate leave.

I = 2

L= 4

8

Commissioner (AD) oversight of provider actions to increase recruitment

Successful recruitment to fill vacancies

No restriction to service delivery

Ability to offer service 7 days per week

I = 2

L= 2

4

Action

Recruitment to vacant posts.

Action owner:

Rachel Lissauer, AD, Clinical Commissioning


November 2013

Locum Consultant (Dr Gaby Brogan) now in place.

Nursing posts are now filled.

Plans for nurse prescribing training in place and communications in next GP Bulletin.

Quality Alert System is in place to monitor and request GP feedback.



41 11.9.14

Strategic Risk Scoring Methodology

IMPACT

1 Negligible 2 Minor 3 Moderate 4 Major

5 Catastrophic

Adverse publicity / reputation

Coverage in media, little effect on public confidence / staff morale

Local Media – short term. Minor effect on public attitudes / staff morale

Local Media – long term. Impact on staff morale & public perception of organisation

National media <3 days Public confidence in organisation undermined. Usage of services affected

National media >3 days. MP Concern (questions in House)

Business objectives / projects

Insignificant cost increase/schedule slippage

Less than 5 per cent over project budget. Schedule slippage.

5 to 10 per cent over project budget. Schedule slippage.

Non-compliance with national 10-25 per cent over project budget. Schedule slippage. Key objectives not met.

Incident leading to over 25 per cent over project budget. Schedule slippage. Key objectives not met.

Finance including claims

Small loss. Risk of claim remote.

Loss of 0.05 – 0.125 per cent of budget per CCG. Claim less than 10,000 GBP.

Loss of 0.125 - 0.25 per cent of budget per CCG. Claim(s) between 10,000 GBP and 100,000 GBP.

Uncertain delivery of key objective/loss of 0.25 - 0.5 per cent of budget per CCG. Claim(s) between 100,000 GBP and 1 million GBP. Purchasers failing to pay on time.

Non-delivery of key objective/loss of over 0.5 per cent of budget per CCG. Failure to meet specifications /slippage. Loss of contract/payment by results. Claim(s) of over 1 million GBP.

HR / organisational development / staffing / competence

Short/term low staffing level that temporarily reduces service quality (less than 1 day).

Low staffing level that reduces the service quality.

Late delivery of key objective/service due to lack of staff. Unsafe staffing level or competence (greater than 1 day). Low staff morale. Poor staff attendance for mandatory/key training.

Uncertain delivery of key objective/service due to lack of staff. Unsafe staffing level or competence (greater than 5 days). Very low staff morale. No staff attending mandatory/key training.

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.

Impact on the safety of patients, staff or public

Minimal injury requiring no/minimal intervention or treatment. No time off work.

Minor injury or illness requiring minor intervention. Requiring time off work for over 3 days. Increase in length of hospital stay by 1-3 days.

Major injury requiring professional intervention. Requiring time off work for 4-14 days. Increase in length of hospital stay by 4-15 days. RIDDOR/agency reportable incident. An event which impacts on a small number of patients.

Major injury leading to long-term incapacity/disability. Requiring time off work for over 14 days. Increase in length of hospital stay by over 15 days. Mismanagement of patient care with long-term effects.

Incident leading to death. Multiple permanent injuries or irreversible health effects. An event which impacts on a large number of patients.



42 11.9.14

1 Negligible 2 Minor 3 Moderate 4 Major

5 Catastrophic

Quality / Complaints/ Audit

Peripheral element of treatment or service suboptimal. Informal complaint/inquiry.

Overall treatment or service suboptimal. Formal complaint (stage 1). Local resolution. Single failure to meet internal standards. Minor implications for patient safety if unresolved. Reduced performance rating is unresolved.

Treatment or service has significantly reduced effectiveness. Formal complaint (stage 2) complaint. Local resolution (with potential to go to independent review). Repeated failure to meet internal standards.

Non-compliance with national standards with significant risk to patients if unresolved. Multiple complaints/independent review. Low performance rating. Critical report.

Totally 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.

Service business interruption / Environmental impact

Loss/interruption of over 1 hour. Minimal or no impact on the environment.

Loss/interruption of over 8 hours. Minor impact on environment.

Loss/interruption of over 1 day. Moderate impact on environment.

Loss/interruption of over 1 week. Major impact on environment.

Permanent loss of service or facility. Catastrophic impact on environment.

Statutory duty / Inspections

No or minimal impact or breach of guidance/statutory duty.

Breach of statutory legislation. Reduced performance rating if unresolved.

Single breech in statutory duty. Challenging external recommendations/improvement notice.

Enforcement action. Multiple breeches in statutory duty. Improvement notices. Low performance rating. Critical report.

Multiple breeches in statutory duty. Prosecution. Complete systems change request. Zero performance rating. Severely critical report.

Information Governance / Information Security

Minor breach of confidentiality. Less than 5 people affected or risk assessed as low, e.g. files were encrypted

Serious potential breach & risk assessed high e.g. unencrypted clinical records lost. Up to 20 people affected

Serious breach of confidentiality e.g. up to 100 people affected

Serious breach with either particular sensitivity e.g. sexual health details, or up to 1000 people affected

Serious breach with potential for ID theft or over 1000 people affected



43 11.9.14

LIKELIHOOD

1

2

3

4

5

Rare Unlikely Possible Likely

Almost certain

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