Paper No.
PB/19/158
Report to: Trust Board
Date:
3 December 2019
Report Title:
Board Assurance Framework
Author:
Karen Sullivan, Associate Director of Corporate Services
Presented by:
Karen Sullivan, Associate Director of Corporate Services
Purpose of Report
The purpose of this report is to present the Board Assurance Framework (BAF) for
consideration and assurance.
Type of
Decision-making
Assurance
Consideration
Report
X
Executive Summary
The BAF sets out the principal risks to the Trust’s strategic objectives. It is a summary
document that maps out the control systems in place to mitigate these risks and
confirms the assurances that the Board needs to evidence the effective operation of
these controls. The BAF acts as the Trust’s corporate risk register and records all
corporate level risks. The Trust Board considers the BAF at each meeting.
The BAF is at appendix 1 and has been considered and updated by risk owners and
relevant committees.
At its meeting in October the Trust Board did not request any changes to the BAF.
The Workforce Committee considered the BAF in November 2019 and did not
propose any changes.
The Quality and Governance Committee considered the BAF at meetings in October
and November and made the following recommendations:
• Risk 18 – likelihood rating of current score to be increased to 5 due to the
impact that increased activity and hospital handover delays were having on
the Trust’s ability to respond, despite a significant increase in staff resource.
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• Risk 18 – expected score to be increased to 16 (likelihood and impact both 4)
as it was considered that the mitigating actions would not reduce the level of
risk significantly
• Risk 18 – risk wording to be amended by inserting the word “effectively” so
that the risk reads “There is a risk that we will not be able to respond
effectively to demand during the Winter period”
• Risk 19 - likelihood rating of current score to be increased to 5 due to the
number of Serious Incidents involving a delayed response, making the total
risk 20
• Risk 19 – expected score to be increased to 16 (likelihood and impact both 4)
as it was considered that the mitigating actions would not reduce the level of
risk significantly.
These changes have been made to the BAF.
The Finance and Performance Committee also considered the BAF in October and
made no suggestions for changes to the BAF. The next meeting of the committee is
26 November 2019. If any changes are proposed these will be reported at the Board
meeting.
The Logistics and Estates Committee considered the risk allocated to it (risk 12) in
October and agreed that it should be reviewed to identify additional mitigations
and to consider whether the change in work priorities as a result of winter pressures
might impact on the timescales for delivery of the mitigating actions. The Director
of Finance has reviewed this risk and made changes to the controls and assurance
sections and amended the completion dates of the mitigating actions. These
changes are reflected in the attached BAF.
Risk Owners have also reviewed the BAF and added updates where required. None
of these affect the score or risk wording and all details are provided in the update
sections of the attached BAF.
In considering whether the BAF provides the Board with the assurance it needs to
fulfil its role Board members may wish to consider the following questions as an aide
memoire:
• Is the current risk score appropriate?
• Can the Trust tolerate the expected score, that is the level of risk which will
exist once all planned actions have been implemented, or would the level of
risk still be too high?
• Are the planned mitigating actions sufficient to reduce the level of risk to the
expected score and is it feasible that these actions will be implemented?
• Are further planned mitigating actions required to reduce the risk to a level
which the Trust can tolerate?
• Is the timescale for implementing the planned mitigations acceptable or do
these need to be escalated to reduce the risk score earlier?
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• Are the sources of assurance listed in the BAF sufficient for the Trust Board to
monitor ongoing management of the risk?
Recommendations
That the Trust Board:
•
AGREES the revised wording of risk 18 as set out in the report;
•
AGREES the revised scores for risks 18 and 19;
•
APPROVES the revised Board Assurance Framework;
•
CONFIRMS that the Board Assurance Framework adequately identifies the
organisation’s strategic risks and that the risks are scored at the appropriate
level in line with the Trust Board’s risk appetite; and
•
CONSIDERS whether it has sufficient assurance in relation to the risks included
in the Board Assurance Framework.
Have the following assessments been undertaken in relation to this report?
•
Quality Impact Assessment? Not applicable
•
Equality Impact Assessment? Not applicable
•
Privacy Impact Assessment? Not applicable
Committees or groups this report has already been presented to:
The Quality and Governance Committee considers the BAF at each meeting in order
to provide assurance to the Board on the arrangements for managing the BAF.
Summary of the conclusions of that committee or group:
The committee did not identify any concerns about the management of the BAF at
the last meeting.
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Risk Management:
New risks arising as a result of this
Risk Assessment – current score
report
Likelihood Consequence Score (A x B)
(A)
(B)
Additional risks for the BAF have been
identified within the report
Planned Mitigations
Not applicable
Risk Appetite
The Trust’s risk appetite statement is:
“Our overall risk appetite is moderate. Our tolerance for risk is in general
limited to events where there is little chance of significant repercussion for
the organisation should there be a failure. Where patients are concerned, we
have a low tolerance for risk, particularly where this could have a significant
adverse impact on our patients. With regard to finance and value for money,
we are prepared to accept some limited financial loss but value for money is
our primary concern. We support risk taking in innovation where we can
demonstrate this will lead to commensurate improvements and the risk is
within management control.”
Does the proposal in the report comply with this statement? The Trust Board should consider the Trust’s risk appetite in reviewing the BAF to
ensure that any decisions relating to the BAF comply with the risk appetite.
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Strategic Fit: Which of the following strategic objectives does this report relate to?
The report does not align with any specific strategic objective.
Big 3 – Respond: We will respond to patient needs in the most Relevant
appropriate way (Non-Conveyance, Recruitment, Staffing, Fleet,
Equipment)
We will make full use of the care pathways available, safely treating patients at
home, driving our non-conveyance to hospital
We will recruit and retain the right number of front-line staff with the right
skill-mix to deliver high quality services to patients and meet the standards
expected of us, in line with our clinical operating model
We will ensure we operate a modern fleet with the right number, type and age
of vehicles to meet the needs of our clinical operating model
We will ensure we have the right equipment, ambulances and staff to meet
patient demands and needs
Big 3 - Develop: We will develop our organisation to become
outstanding for patients and staff (Patient Care & Quality, Career
Development, Staff Support, Estate Development, ASI and ACQI
improvement, CQC and Finance)
We will continually strive to improve our reported levels of patient satisfaction
We will continue to develop an organisation that staff and volunteers are proud
to work for
We will ensure our workforce is healthy, engaged, supported and satisfied and
that they demonstrate our EMAS values
We will develop our career frameworks and opportunities for both clinical and
non-clinical staff across the organisation
We will realise benefits from operating a modern and sustainable estate
We will strive to consistently deliver the Ambulance System Indicators and
Ambulance Care Quality Indicators
We will strive to achieve a CQC rating of ‘outstanding’ and will consistently meet
our financial targets
Big 3 – Collaborate: We will collaborate with partners and other
organisations to reduce healthcare demand and improve wider
healthcare (Innovation in Healthcare, Right Healthcare for Patients,
working with 111, Mental Health support, Public Education,
Working in Partnership with STPs/ICSs)
We will lead and contribute to improvements for patients within the East
Midlands, working with partner organisations to deliver innovative healthcare
We will support local communities to access the most appropriate urgent and
emergency care for their needs
We will work with partner organisations to develop our approach to supporting
Mental Health
We will work closely with our partners in 111 to deliver seamless, most
appropriate healthcare to patients
We will continue to focus on public education on the use of 999 services
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Board Assurance Framework – risks as at November 2019
The Board Assurance Framework is also the Trust’s Corporate Risk Register
Respond We will respond to patient needs in the most appropriate way (Non-Conveyance, Recruitment, Staffing,
Fleet, Equipment)
Strategic Objectives:
• We will make full use of the care pathways available, safely treating patients at home, driving our non-
Responsible
Director Risk
Current
conveyance to hospital
• We will recruit and retain the right number of front-line staff with the right skill-mix to deliver high quality
Committee
Owner
score
services to patients and meet the standards expected of us, in line with our clinical operating model
• We will ensure we operate a modern fleet with the right number, type and age of vehicles to meet the needs of
our clinical operating model
• We will ensure we have the right equipment, ambulances and staff to meet patient demands and needs
There is a risk that demand for our services cannot be reduced or increases at a greater rate than planned
Finance and
Performance
1.
Mike Naylor
5 x 4 = 20
Committee
2. Risk merged with risk 9 – August 2019
There is a risk of the absence of, or restricted access to, care pathways; affecting non-conveyance rates and patient
Quality and
3. experience
Governance
Leon Roberts
4 x 4 = 16
Committee
There is a risk that hospital handover delays do not improve, resulting in significant lost resource hours and an inability
Quality and
Nichola
4. to respond to patients
Governance
5 x 4 = 20
Bramhall
Committee
There is a risk that we are unable to deliver our financial target, leading to loss of income
Finance and
5.
Performance
Mike Naylor
4 x 4 = 16
Committee
There is a risk of industrial action as a result of local and national policies, procedures, terms and conditions
Workforce
6.
Committee
Kerry Gulliver
3 x 3 = 9
There is a risk we will experience infrastructure failure and/or data loss
Finance and
7.
Performance
Will Legge
4 x 4 = 16
Committee
There is a risk that Brexit will adversely affect our services
Finance and
8.
Performance
Will Legge
3 x 4 = 12
Committee
There is a risk that we will not be able to respond effectively to demand during the Winter period
Quality and
18.
Governance
Ben Holdaway
5 x 4 = 20
Committee
There is a risk of potential patient harm due to delayed responses if activity levels and hospital handover delays do not
Quality and
reduce and internal efficiencies are not realised
Governance
Nichola
19.
5 x 4 = 20
Committee
Bramhall
BAF 21 November 2019
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Develop We will develop our organisation to become outstanding for patients and staff (Patient Care & Quality,
Career Development, Staff Support, Estate Development, ASI and ACQI improvement, CQC and Finance)
Strategic Objectives:
• We will continually strive to improve our reported levels of patient satisfaction
• We will continue to develop an organisation that staff and volunteers are proud to work for
Responsible
Director Risk
Current
• We will ensure our workforce is healthy, engaged, supported and satisfied and that they demonstrate our
EMAS values
Committee
Owner
score
• We will develop our career frameworks and opportunities for both clinical and non-clinical staff across the
organisation
• We will realise benefits from operating a modern and sustainable estate
• We will strive to consistently deliver the Ambulance System Indicators and Ambulance Care Quality Indicators
• We will strive to achieve a CQC rating of ‘outstanding’ and wil consistently meet our financial targets
There is a risk that we are unable to attract and retain appropriately skilled staff to deliver our clinical model, including
Workforce
9.
Kerry Gulliver
4 x 4 = 16
our skill mix requirement
Committee
There is a risk that we do not develop our workforce, resulting in low morale and the inability to recruit and retain staff
Workforce
10.
Kerry Gulliver
3 x 4 = 12
Committee
There is a risk that we fail to take advantage of the IMT opportunities that would enable our organisation to become
Finance and
11. outstanding
Performance
Will Legge
4 x 3 = 12
Committee
There is a risk that we are unable to modernise our estate or develop Make Ready to support the clinical model
Logistics and
12.
Estates
Mike Naylor
3 x 4 = 12
Committee
There is a risk we will be unable to demonstrate compliance with the strategic equalities framework and standards
Workforce
16.
Kerry Gulliver
3 x 3 = 9
Committee
There is a risk that we will not have sufficient frontline leaders
Workforce
17.
Ben Holdaway
4 x 3 = 12
Committee
Collaborate We will collaborate with partners and other organisations to reduce healthcare demand and improve
wider healthcare (Innovation in Healthcare, Right Healthcare for Patients, Working with 111, Mental Health support,
Public Education, Working in Partnership with STPs/ICSs)
• We will lead and contribute to improvements for patients within the East Midlands, working with partner
Responsible
Director Risk
Current
organisations to deliver innovative healthcare
Committee
Owner
score
• We will support local communities to access the most appropriate urgent and emergency care for their needs
• We will work with partner organisations to develop our approach to supporting Mental Health
• We will work closely with our partners in 111 to deliver seamless, most appropriate healthcare to patients
• We will continue to focus on public education on the use of 999 services
13. Risk removed – August 2019
14. Risk merged with risk 1 – August 2019
There is a risk that we are unable to improve healthcare because we have little influence in the emerging new
Finance and
15. healthcare systems
Performance
Will Legge
4 x 4 = 16
Committee
BAF 21 November 2019
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Risk Score Matrix
c
5
10
15
20
25
rophits
at
a
C
5
4
8
12
16
20
or
Maj
4
3
6
9
12
15
e
T
t
a
C
A
der
MP
I
Mo
3
2
4
6
8
10
r no
Mi
2
1
2
3
4
5
elbigigle N1
Rare
Unlikely
Possible
Likely
Almost
1
2
3
4
Certain
5
LIKELIHOOD
BAF 21 November 2019
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Risk No. 01
Strategic objective: Respond
Risk description
There is a risk that demand for our services cannot be reduced or increases at a greater rate than planned
How will it manifest? Insufficient resources to respond to demand leading to delays, complaints, incidents involving patient harm or clinical concerns,
performance below national standards and reputational impact
Risk owner
Finance and Performance
Mike Naylor
Risk committee
Risk source Risk Workshop May 2019
Committee
Current Score
Expected Score
Likelihood
Impact
Total
Likelihood
Impact
Total
5
4
20
4
3
12
Most recent scores
November
October
September
August
July
20
20
20
20
16
Controls and Assurances
Internal/
+ve/
Key Controls and/or Activity in place
Source of Board Assurance for the controls
External
-ve
Annual process for negotiating contract
Integrated Board Report
I
-ve
Continuous monitoring of activity against assumptions in the contract which would identify trends in demand
Updates to Finance and Performance
Committee and Trust Board on contract
-ve/
I
negotiations including activity assumptions
+ve
Daily monitoring of resources and operational performance against national standards
Record of Business from Executive Team
I
-ve
Business meetings
Escalation of increasing demand with commissioners, to aid in system-wide resolutions to growth
Gaps in Assurance or Control and Mitigating Actions
Gaps in Assurance or Control
Mitigating Action(s)
Action Owner
Completion Date
Status
Implementation of 2019/20 Workforce Plan to increase current level
Resourcing levels
Kerry Gulliver
31 March 2020
G
of staff resource
Implementation of the clinical operating model with advanced
practice, leading to delivery of Ambulance Response Programme
Resourcing levels
Leon Roberts
31 March 2020
G
principals (right resource, right patient, right time), leading to greater
operational resource availability
BAF 21 November 2019 Page
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Update – November 2019
Any new controls & assurances?
Any new gaps or mitigating actions?
Any changes to current score?
Any changes to expected score?
No updates proposed by lead committee or risk owner
Risk 2 merged with risk 9
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Risk No. 03
Strategic objective: Respond
Risk description
There is a risk of the absence of, or restricted access to, care pathways; affecting non-conveyance rates and patient experience
How will it manifest? Inappropriate conveyances resulting in poor patient experience and fewer resources to respond to other calls resulting in delays,
complaints, incidents involving patient harm or clinical concerns, performance below national standards and reputational impact
Risk owner
Quality and Governance
Leon Roberts
Risk committee
Risk source Risk Workshop May 2019
Committee
Current Score
Expected Score
Likelihood
Impact
Total
Likelihood
Impact
Total
4
4
16
4
4
16
Most recent scores
November
October
September
August
July
16
16
16
16
16
Controls and Assurances
Internal/
+ve/
Key Controls and/or Activity in place
Source of Board Assurance for the controls
External
-ve
Active involvement in Sustainability and Transformation Partnerships and Integrated Care Systems
resulting in opportunities to raise the need for further care pathways
Care pathway information available for staff on GTAC equipment used for patient records
Gaps in Assurance or Control and Mitigating Actions
Gaps in Assurance or Control
Mitigating Action(s)
Action Owner
Completion Date
Status
Access to clinical pathways
To undertake a trial in Lincolnshire with access to clinical pathways
Leon Roberts
TBC
G
available on GTAC
Update – November 2019
Any new controls & assurances?
Any new gaps or mitigating actions?
Any changes to current score?
Any changes to expected score?
No updates proposed by lead committee or Risk Owner
BAF 21 November 2019 Page
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Risk No. 04
Strategic objective: Respond
Risk description
There is a risk that hospital handover delays do not improve, resulting in significant lost resource hours and an inability to respond to
patients
How will it manifest? Complaints, incidents involving patient harm and/or poor experience, sub-optimal clinical outcomes, performance below national
standards and reputational impact
Risk owner
Quality and Governance
Nichola Bramhall
Risk committee
Risk source
Risk Workshop May 2019
Committee
Current Score
Expected Score
Likelihood
Impact
Total
Likelihood
Impact
Total
5
4
20
5
4
20
Most recent scores
November
October
September
August
July
20
20
20
16
16
Controls and Assurances
Internal/
+ve/
Key Controls and/or Activity in place
Source of Board Assurance for the controls
External
-ve
Attendance and influence at Accident and Emergency Delivery Boards to identify
Integrated Board Report
I
-ve
solutions
EMAS managers available to attend Emergency Departments at periods of significant
Serious and High-Level Incident Performance report to Quality and
I
-ve
pressure
Governance Committee
Access to third party resource during periods of pressure
Post handover phase monitored and managed through divisional Performance Review
Meetings
Risk sharing included in contract to reduce the impact of significant delays
Agreed escalation processes in place with acute providers and commissioners
enacted during sustained poor pre-handover performance
Pre-handover phase monitored and managed through County Contract Management
Meetings with rapid improvement plans agreed as appropriate (escalated to Strategic
Delivery Board with Commissioners if required)
Implementation of divisional tactical cells to monitor and address internal and external
efficiencies in real time
BAF 21 November 2019 Page
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Gaps in Assurance or Control and Mitigating Actions
Gaps in Assurance or Control
Mitigating Action(s)
Action Owner
Completion Date
Status
The impact of handover delays
Introduce a quarterly report to the Quality and Governance Committee
Nichola Bramhall
31 October 2019
G
on all three domains of quality is assessing the impact of operational performance (including handover
not routinely analysed
delays) on patient safety, experience and clinical outcomes
Assessment of impact handover
Undertake a comparative risks assessment of the impact of hospital
Nichola Bramhall
Completed
G
delays on all patients
handover delays on patients in the community waiting for a response
and those waiting at hospital.
Acknowledgement of risk to
Implement Rapid Handover Protocol in Lincolnshire
Ben Holdaway
Was September
A
patients by acute trusts
2019
Now 20 November
2019
Explore the feasibility of implementing a Rapid Handover Protocol in
Ben Holdaway
31 January 2020
G
other systems
Update – November 2019
Any new controls & assurances?
Any new gaps or mitigating actions?
Any changes to current score?
Any changes to expected score?
Mitigation is largely dependent upon the actions of other organisations and therefore the expected risk score is recorded at the same level as the current score
Since the last update the comparative risk assessment has been completed and considered by the Trust’s Clinical Governance Group on 14 October 2019.
Controls section updated and additional action regarding the feasibility of Rapid Handover Protocols in other systems added – November 2019
Agreement to implement the Rapid Handover Protocol in Lincolnshire was approved at the Lincolnshire Urgent and Emergency Care Stocktake meeting on 8 October 2019 - a
go live date of 4 November 2019 was agreed to allow time for joint staff briefings which are underway.
A meeting between the EMAS and Leicester Royal Infirmary Chief Executives, Directors of Operations, Directors of Nursing/ Quality and Medical Directors took place on 17
October 2019 to discuss the feasibility of implementing a Rapid Handover Protocol, work is now underway to look at how the protocol will need to be amended for use in the
Leicestershire system.
Completion date Rapid Handover Protocol amended by action owner – November 2019
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Risk No. 05
Strategic objective: Respond
Risk description
There is a risk that we are unable to deliver our financial target, leading to loss of income
How will it manifest? Reputational impact and insufficient resources to respond to demand leading to delays, complaints, incidents involving patient harm
or clinical concerns, performance below national standards and reputational impact
Risk owner
Finance and Performance
Mike Naylor
Risk committee
Risk source Risk Workshop May 2019
Committee
Current Score
Expected Score
Likelihood
Impact
Total
Likelihood
Impact
Total
4
4
16
4
4
16
Most recent scores
November
October
September
August
July
16
16
16
16
16
Controls and Assurances
Internal/
+ve/
Key Controls and/or Activity in place
Source of Board Assurance for the controls
External
-ve
Frequent financial monitoring
Integrated Board Report including finance section
I
+ve
Cost Improvement Programme monitored by Programme Management Office
Monthly finance report to Finance and Performance Committee
I
+ve
NHS Improvement monthly review of EMAS
Gaps in Assurance or Control and Mitigating Actions
Gaps in Assurance or Control
Mitigating Action(s)
Action Owner
Completion Date
Status
Update – November 2019
Any new controls & assurances?
Any new gaps or mitigating actions?
Any changes to current score?
Any changes to expected score?
No updates proposed by lead committee or Risk Owner
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Risk No. 06
Strategic objective: Respond
Risk description
There is a risk of industrial action as a result of local and national policies, procedures, terms and conditions
How will it manifest? Inability to respond to patients leading to, complaints, incidents involving patient harm or clinical concerns, performance below
national standards and reputational impact
Risk
Risk owner Kerry Gulliver
Risk committee
Workforce Committee source
Risk Workshop May 2019
Current Score
Expected Score
Likelihood
Impact
Total
Likelihood
Impact
Total
3
3
9
3
3
9
Most recent scores
November
October
September
August
July
9
9
9
9
9
Controls and Assurances
Internal/
+ve/
Key Controls and/or Activity in place
Source of Board Assurance for the controls
External
-ve
Trust Partnership Forum meetings and Trade Union Communications meetings
Trust Partnership Forum minutes presented to
+ve/
I
-ve
Workforce Committee
Divisional Partnership Forum meetings
Sub Group Records of Business presented to
Partnership Agreement with trade unions
+ve/
Workforce Committee
I
-ve
Trade Union representation on Workforce Committee
Engagement in national ambulance partnership working group (NASPF)
Gaps in Assurance or Control and Mitigating Actions
Gaps in Assurance or Control
Mitigating Action(s)
Action Owner
Completion Date
Status
Update – November 2019
Any new controls & assurances?
Any new gaps or mitigating actions?
Any changes to current score?
Any changes to expected score?
No updates proposed by lead committee or Risk Owner
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Risk No. 07
Strategic objective: Respond
Risk description
There is a risk we will experience infrastructure failure and/or data loss
How will it manifest? Inability to respond to patients promptly; investigation by Information Commission; fines; reputational impact
Finance and
Risk
Risk owner
Will Legge
Risk committee
Performance
source
Risk Workshop May 2019
Committee
Current Score
Expected Score
4
4
16
3
4
12
Most recent scores
November
October
September
August
July
16
16
16
16
16
Controls and Assurances
Internal/
+ve/
Key Controls and/or Activity in place
Source of Board Assurance for the controls
External
-ve
Information Management & Technology Strategy
Regular reporting to Finance and Performance
I
+ve
Information Security Strategy (Cyber Strategy)
Committee on Information Management and
Information Governance Group
Technology projects and information governance
Data Protection Officer, Senior Information Risk Owner, Caldicott Guardian and General Data Protection
issues
Regulation (GDPR) Non Executive Director lead
Regular training and awareness for staff regarding Information Governance responsibilities
Continuing investment in information technology through Financial Plan including Capital Programme
Active monitoring and reporting of security for external/internet facing devices
Enhanced Computer Aided Dispatch connectivity/resilience in place
Upgraded Trust telephony platform in place
Core network data links between core EMAS HQ and EOC sites replaced
Routine audits of system resilience undertaken, including Business Continuity Plan tests
Information Governance policies and procedures including DSPT actions
Formal governance structure to monitor GDPR
Formal incident reporting process in place for GDPR related issues
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Gaps in Assurance or Control and Mitigating Actions
Gaps in Assurance or Control
Mitigating Action(s)
Action Owner
Completion Date
Status
CAD long term resilience
Procurement of replacement CAD solution, focussing on
Steve Bowyer
Was 1 April 2020
G
resilience
now 1 April 2022
Live
Cloud based server provision
Systematically review age profile and applicability of transitioning
Steve Bowyer
31 December 2019
G
existing physical servers to cloud operations and create phased
plan for transition
Data Security and Protection
DSPT remedial action plan actions completed, including
Steve Bowyer
30 September 2019
G
Toolkit (DSPT) Remediations
penetration testing and cyber security resources
– action complete
Cyber Security Provision
Agree and implement revised cyber security structure within
Steve Bowyer
Was 31 October
G
Information Management and Technology team
2019 now 31
December 2019
CAD short-medium term resilience
Replacement of core switches for telephony and data combined
Steve Bowyer
31 December 2019
G
with CAD system hardware refresh
Update – November 2019
Any new controls & assurances?
Any new gaps or mitigating actions?
Any changes to current score?
Any changes to expected score?
Action relating to DSPT remedial action plan complete – controls section updated accordingly – November 2019
Additional action relating to replacement of core switches added November 2019
Completion date for cyber security structure action amended by Risk Owner – November 2019
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Risk No. 8
Strategic objective: Respond
Risk description
There is a risk that Brexit will adversely affect our services
How will it manifest? Rise in non pay costs leading to inability to meet financial targets; problems in obtaining consumables due to customs delays and
delays in responding to patients due congested roads near ports
Risk owner
Finance and Performance
Will Legge
Risk committee
Risk source Risk Workshop May 2019
Committee
Current Score
Expected Score
Likelihood
Impact
Total
Likelihood
Impact
Total
3
4
12
3
4
12
Most recent scores
November
October
September
August
July
12
12
12
12
12
Controls and Assurances
Internal/
+ve/
Key Controls and/or Activity in place
Source of Board Assurance for the controls
External
-ve
Regular budget monitoring
Reports to Finance and Performance Committee
I
+ve
Lead Director for Brexit
Brexit Update report to Trust Board
I
+ve
Weekly Brexit internal co-ordination call
Attendance at national and regional Brexit planning meetings (NHS Improvement /NHS England)
Attendance at Local Resilience Forum meetings in each county area
Gaps in Assurance or Control and Mitigating Actions
Gaps in Assurance or Control
Mitigating Action(s)
Action Owner
Completion Date
Status
Update – November 2019
Any new controls & assurances?
Any new gaps or mitigating actions?
Any changes to current score?
Any changes to expected score?
No updates proposed by lead committee or Risk Owner
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Risk No. 9
Strategic objective: Develop
Risk description
There is a risk that we are unable to attract and retain appropriately skilled staff to deliver our clinical model, including our skill mix
requirement
How will it manifest? Insufficient or inappropriate resources to respond to demand leading to delays, complaints, incidents involving patient harm or
clinical concerns, performance below national standards and reputational impact
Risk owner
Kerry Gulliver
Risk committee
Workforce Committee Risk source
Risk Workshop May 2019
Current Score
Expected Score
Likelihood
Impact
Total
Likelihood
Impact
Total
4
4
16
3
4
12
Most recent scores
November
October
September
August
July
16
16
16
16
16
Controls and Assurances
Internal/
+ve/
Key Controls and/or Activity in place
Source of Board Assurance for the controls
External
-ve
Recruitment process linked to Workforce Plan requirements
Integrated Board Report
I
+ve
Monthly monitoring of workforce metrics by Executive Team
Workforce Committee workforce metrics
I
+ve
Regular monitoring of staff turnover and exit interviews
Report to Workforce Committee on staff turnover and
I
+ve
exit interviews
Monitoring of skill mix
Workforce Committee Records of Business and
+ve/
I
minutes
-ve
Staff engagement initiatives
Mandatory education for line managers to support staff and to lead healthy workplaces
Suite of Human Resource policies and procedures
Staff Wellbeing and support initiatives
Monitoring of the implementation of the People and Organisational Development Strategy through the
Workforce Committee
Gaps in Assurance or Control
Mitigating Action(s)
Action Owner
Completion Date
Status
Career opportunities to be developed through the implementation of the
31 March
G
Leon Roberts
Clinical Model
2020
31 March
Deliver of Workplace and Education Plan 2019/20
G
Kerry Gulliver
2020
Liaise with Primary Care Networks regarding the Trust’s proposals in terms
31 March
Will Legge
G
of recruitment of paramedics
2020
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Update – November 2019
Any new controls & assurances?
Any new gaps or mitigating actions?
Any changes to current score?
Any changes to expected score?
Minor amendments to wording of actions, addition of Board assurance and action completion date – by Risk Owner November 2019
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Risk No. 10
Strategic objective: Develop
Risk description
There is a risk that we do not develop our workforce, resulting in low morale and the inability to recruit and retain staff
How will it manifest? Insufficient or inappropriate resources to respond to demand leading to delays, complaints, incidents involving patient harm or
clinical concerns, performance below national standards and reputational impact
Risk owner
Kerry Gulliver
Risk committee
Workforce Committee
Risk source Risk Workshop May 2019
Current Score
Expected Score
Likelihood
Impact
Total
Likelihood
Impact
Total
3
4
12
2
4
8
Most recent scores
November
October
September
August
July
12
12
12
12
12
Controls and Assurances
Internal/
+ve/
Key Controls and/or Activity in place
Source of Board Assurance for the controls
External
-ve
Workforce metrics presented to Workforce
Clinical Model will provide opportunity for Specialist and Advanced Practice roles
I
+ve
Committee
Career Progression routes in place from Urgent Care Assistant, Emergency Care Assistant or Emergency
Report on exit interview analysis considered by
Medical Dispatcher to Technician and Technician to Paramedic
Workforce Committee
Rotational Models
Clinical Operating Model business case
I
+ve
+ve/
Paramedic to First Line Manager career progression routes
Workforce Committee Records of Business
I
-ve
Access to funded education through Higher Education Institutes and Health Education England
Access to Continuing Professional Development
Cultural Audit
Gaps in Assurance or Control and Mitigating Actions
Gaps in Assurance or Control
Mitigating Action(s)
Action Owner
Completion Date
Status
Implementation of new career opportunities through the Clinical Model
Leon Roberts
31 March 2020
G
Update – November 2019
Any new controls & assurances?
Any new gaps or mitigating actions?
Any changes to current score?
Any changes to expected score?
Board assurance added by Risk Owner – November 2019
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Risk No. 11
Strategic objective: Develop
Risk description
There is a risk that we fail to take advantage of the IMT opportunities that would enable our organisation to become
Outstanding
How will it manifest? Insufficient resources to respond to demand resulting in leading to delays, complaints, incidents involving patient harm or clinical
concerns, performance below national standards and reputational impact
Risk owner
Finance and Performance
Will Legge
Risk committee
Risk source Risk Workshop May 2019
Committee
Current Score
Expected Score
4
3
12
3
3
9
November
October
September
August
July
12
12
12
12
12
Controls and Assurances
Internal/
+ve/
Key Controls and/or Activity in place
Source of Board Assurance for the controls
External
-ve
Information Management and Technology Strategy
Regular reporting to Finance and Performance Committee
I
+ve
Routine engagement between Information Management and Technology Strategic
leaders and Strategy team including Clinical Operating Model development processes
Associate Director of Digital Transformation is chair of national ambulance Information
Technology leads meeting and attends national ambulance and NHS X meetings to
drive strategy
Associate Director of Digital Transformation fully engaged with commissioner-driven
developments including Commissioning for Quality and Innovation schemes related to
digital transformation
Gaps in Assurance or Control and Mitigating Actions
Gaps in Assurance or Control
Mitigating Action(s)
Action Owner
Completion Date
Status
Implementation of Strategy
Implement plans to deliver Information Management and Technology
Will Legge
TBC
G
Strategy
Capacity for full engagement
with local Sustainability and
Transformation Partnerships
To carry out a prioritisation of initiatives
Steve Bowyer
31 August 2019
G
(STP)/ Integrated Care
Systems (ICS)
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Update – November 2019
Any new controls & assurances?
Any new gaps or mitigating actions?
Any changes to current score?
Any changes to expected score?
No updates proposed by lead committee or Risk Owner
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Risk No. 12
Strategic objective: Develop
Risk description
There is a risk that we are unable to modernise our estate or develop Make Ready to support the clinical model
How will it manifest? Delays in responding to calls due to resources being in the wrong location leading to complaints, incidents involving patient harm or
clinical concerns, performance below national standards and reputational impact
Risk owner
Logistics and Estates
Mike Naylor
Risk committee
Risk source
Risk Workshop May 2019
Committee
Current Score
Expected Score
Likelihood
Impact
Total
Likelihood
Impact
Total
3
4
12
2
4
8
Most recent scores
November
October
September
August
July
12
12
12
12
12
Controls and Assurances
Internal/
+ve/
Key Controls and/or Activity in place
Source of Board Assurance for the controls
External
-ve
Capital Programme
Regular monitoring of progress to Logistics and Estates
I
+ve
Committee
Make Ready Early Adopter sites at Kings Mill and Gorse Hill stations
Periodic report to Finance and Performance Committee on Make
I
+ve
Read
Gaps in Assurance or Control and Mitigating Actions
Gaps in Assurance or Control
Mitigating Action(s)
Action Owner
Completion Date
Status
Was 31 October
Develop and implement Make Ready business case
Dave Whiting
2019 now 31
G
January 2020
Was 31 October
Identify funding for implementation of full Make Ready programme
Mike Naylor
2019 now 31
G
January 2020
Update – November 2019
Any new controls & assurances?
Any new gaps or mitigating actions?
Any changes to current score?
Any changes to expected score?
Control relating to early adopter sites and Board Assurance added and completion dates amended by Risk Owner – November 2019
Risk 13 removed
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Risk 14 merged with risk 1
Risk No. 15
Strategic objective: Collaborate
Risk description
There is a risk that we are unable to improve healthcare because we have little influence in the emerging new healthcare systems
How will it manifest? Reputational Impact
Finance and
Risk owner
Will Legge
Risk committee
Performance
Risk source Risk Workshop May 2019
Committee
Current Score
Expected Score
Likelihood
Impact
Total
Likelihood
Impact
Total
4
4
16
4
4
16
Most recent scores
November
October
September
August
July
16
16
16
16
16
Controls and Assurances
Internal/
+ve/
Key Controls and/or Activity in place
Source of Board Assurance for the controls
External
-ve
Regular liaison with Sustainability and Transformation Partnerships and Integrated Care
Integrated Board Report
Systems
Clinical Indicators Report presented to Quality and Governance
Monitor of performance against Ambulance Clinical Quality Indicators
Committee
Attendance at Accident and Emergency Boards
I
-ve
I
-ve
Sharing of Clinical Operating Model and ‘big 3’ strategy with key stakeholders and STP/ICSs
Development of primary care network ‘offer’, related to the advancement of the clinical model
advanced practice implementation
Central oversight of the STP/ICS long term plan implementation plans
Gaps in Assurance or Control and Mitigating Actions
Gaps in Assurance or Control
Mitigating Action(s)
Action Owner
Completion Date
Status
Identification and management
Undertake stakeholder mapping exercise, prioritising engagement to key
Will Legge
Was 30 September
G
of key stakeholders
areas
2019
Now 31 December
2019
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Modelling capability
Tender for and procure a Trust-wide modelling tool, giving enhanced
Will Legge
Was 31 October
G
capability of understanding system changes and impact of EMAS
2019
schemes and operational changes
Now 30 November
2019
Update – November 2019
Any new controls & assurances?
Any new gaps or mitigating actions?
Any changes to current score?
Any changes to expected score?
Completion dates for actions extended by Risk Owner - November 2019
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Risk No. 16
Strategic objective: Develop
Risk description
There is a risk we will be unable to demonstrate compliance with the strategic equalities framework and standards
How will it manifest? Legal challenge resulting in reputational and financial implications
Risk owner
Kerry Gulliver
Risk committee
Workforce Committee Risk source
Workforce Committee July 2019
Current Score
Expected Score
Likelihood
Impact
Total
Likelihood
Impact
Total
3
3
9
3
3
9
Most recent scores
November
October
September
August
9
9
9
9
Controls and Assurances
Internal/
+ve/
Key Controls and/or Activity in place
Source of Board Assurance for the controls
External
-ve
Equality, Diversity and Inclusion Strategy and Annual Report
Equality and Diversity quarterly update to Workforce Committee
I
+ve
Equality Delivery System 2 Assessment
Equality, Diversity and Inclusion Annual Report to Workforce
I
+ve
Equalities evidence database and Workforce Race Equality Standard/ Workforce Disability
Committee and Trust Board
Equality Standard data
Internal Audit Review 2018/19 Review of Equality Impact
E
+ve
Monitoring against standards
Assessments
Improved process for ensuring Equality Impact Assessments are completed for all policies
and procedures
Black and Minority Ethnic Network and Lesbian, Gay, Bisexual and Transgender Network
Gaps in Assurance or Control and Mitigating Actions
Gaps in Assurance or Control
Mitigating Action(s)
Action Owner
Completion Date
Status
Update – November 2019
Any new controls & assurances?
Any new gaps or mitigating actions?
Any changes to current score?
Any changes to expected score?
Minor amendments to controls by Risk Owner – November 2019
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Risk No. 17
Strategic objective: Develop
Risk description
There is a risk that we will not have sufficient frontline leaders
How will it manifest? Reduced staff morale; patient safety and clinical effectiveness incidents; and reputational impact
Risk owner Ben Holdaway
Risk committee
Workforce Committee
Risk source Workforce Committee 22 August 2019
Current Score
Expected Score
Likelihood
Impact
Total
Likelihood
Impact
Total
4
3
12
4
3
12
Most recent scores
November
October
September
12
12
12
Controls and Assurances
Internal/
+ve/
Key Controls and/or Activity in place
Source of Board Assurance for the controls
External
-ve
Guiding principles of clinical model set out in ‘big 3’ vision and business ambitions agreed by Trust
Board
Clinical model workshop held with senior leaders to identify key clinical areas for improvement
Gaps in Assurance or Control and Mitigating Actions
Gaps in Assurance or Control
Mitigating Action(s)
Action Owner
Completion Date
Status
Lack of clarity regarding clinical
Development of Clinical Model which will include frontline clinical leadership
TBC
model
arrangements
Will Legge
Management capacity
Review of Operational Management Structure
31 March 2020
Ben Holdaway
G
Update – November 2019
Any new controls & assurances?
Any new gaps or mitigating actions?
Any changes to current score?
Any changes to expected score?
Mitigating action relating to Operational Management Structure added November 2019
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Risk No. 18
Strategic objective: Respond
Risk description
There is a risk that we will not be able to respond effectively to demand during the Winter period
How will it manifest? Impact on provision of services
Quality and
Quality and Governance
Risk owner Ben Holdaway
Risk committee
Governance
Risk source Committee meeting
Committee
17 September 2019
Current Score
Expected Score
Likelihood
Impact
Total
Likelihood
Impact
Total
5
4
20
4
4
16
Most recent scores
November
October
September
20
16
16
Controls and Assurances
Internal/
+ve/
Key Controls and/or Activity in place
Source of Board Assurance for the controls
External
-ve
Winter Concept of Operations Plan in place
Consideration of Winter Concept of Operations Plan by Trust
+ve
Board
I
Capacity Management Plan in place
Integrated Board Report
I
+ve
Performance management at Trust Board and committee level through contract metrics
I
-ve
Monthly reporting of operational performance to Finance and
report
Performance Committee
Local escalation meetings with NHS England/ NHS Improvement and Acute Hospitals
Monthly national conference call
National Ambulance Co-ordination Centre established and supporting work on the resolution
of hospital handover delays
Existing Private Ambulance Service levels maintained for quarter four
Gaps in Assurance or Control and Mitigating Actions
Gaps in Assurance or Control
Mitigating Action(s)
Action Owner
Completion Date
Status
Actions to address winter
To implement the Winter Concept of Operations Plan
Ben Holdaway
30 November 2019
G
pressures
Involvement of partners
20 November 2019
Development of a Rapid Handover Protocol
Ben Holdaway
A
organisations
for Lincolnshire
Incentive scheme to encourage take-up of overtime in December and
Resourcing
Ben Holdaway
December 2019
G
January
Update – November 2019
Any new controls & assurances?
Any new gaps or mitigating actions?
Any changes to current score?
Any changes to expected score?
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Wording of risk amended to add the word “effectively” – proposed by Quality and Governance Committee 19 November 2019
Current score amended to likelihood of 5 – total score 20 and expected score amended to likelihood of 4 and impact of 4 - total score 16 – proposed by Quality and Governance
Committee 19 November 2019
Additional controls relating to the National Ambulance Co-ordination Centre and Private Ambulance Service resourcing added by Risk Owner – November 2019
Additional mitigating action relating to Incentive Scheme added by Risk Owner November 2019
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Risk No. 19
Strategic objective: Respond
Risk description
There is a risk of potential patient harm due to delayed responses if activity levels and hospital handover delays do not
reduce and internal efficiencies are not realised
How will it manifest? Serious or High Level Incidents, complaints
Quality and
Quality and Governance
Risk owner Nichola Bramhall
Risk committee
Governance
Risk source Committee meeting
Committee
17 September 2019
Current Score
Expected Score
Likelihood
Impact
Total
Likelihood
Impact
Total
5
4
20
4
4
16
Most recent scores
November
October
September
20
12
12
Controls and Assurances
Internal/
+ve/
Key Controls and/or Activity in place
Source of Board Assurance for the controls
External
-ve
Winter Concept of Operations Plan in place
Consideration of Winter Concept of Operations Plan by Trust
+ve
Board
I
Capacity Management Plan in place
Integrated Board Report
I
+ve
Performance management of response times at Trust Board and committee level through
I
-ve
Monthly reporting of operational performance to Finance and
contract metrics report
Performance Committee
Involvement in Accident and Emergency Delivery Boards
Handover protocols with individual Acute Trusts
Monitoring of incidents to identify any trends relating to potential harm
Monitoring of Prolonged Waits
Implementation of divisional tactical cells to monitor internal and external efficiencies in real
time
Existing Private Ambulance Service levels maintained for quarter four
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Gaps in Assurance or Control and Mitigating Actions
Gaps in Assurance or Control
Mitigating Action(s)
Action Owner
Completion Date
Status
Actions to address winter
To implement the Winter Concept of Operations Plan
Ben Holdaway
30 November 2019
G
pressures
Was 4 November
Implementation of Rapid Handover Protocol in Lincolnshire
Ben Holdaway
2019 now 20
A
November 2019
Explore the feasibility of implementing a Rapid Handover Protocol in other
Engagement from partners
Ben Holdaway
31 January 2020
A
systems
Undertake a risk assessment in conjunction with relevant providers
30 September 2019
comparing the risk to patients at hospital with that of those in the
Nichola Bramhall
–
G
completed
community awaiting a response from EMAS
Implementation of Workforce Plan to increase staffing levels
Kerry Gulliver
31 March 2020
A
Lack of resources
Engagement with commissioners regarding funding through contract
Mike Naylor
31 March 2020
A
negotiations
There is currently no system
Work with co-ordinating and associate commissioners and system
wide process for assessing
providers to develop a process for assessing the harm due to prolonged
Nichola Bramhall
31 January 2020
A
harm due to prolonged delays
delays
Incentive scheme to encourage take-up of overtime in December and
Resourcing
Ben Holdaway
December 2019
G
January
Update – November 2019
Any new controls & assurances?
Any new gaps or mitigating actions?
Any changes to current score?
Any changes to expected score?
Current likelihood score increased to 5 – total score 20 and expected score increased to 4 for likelihood and 4 for impact – total score 16 proposed by the Quality and
Governance Committee October and November 2019
Since the last update the comparative risk assessment has been completed and considered by the Trust’s Clinical Governance Group on 14 October 2019.
Controls section updated and additional actions regarding the feasibility of Rapid Handover Protocols in other systems and developing a process for assessing harm due to
prolonged delays added – November 2019
Agreement to implement the Rapid Handover Protocol in Lincolnshire was approved at the Lincolnshire Urgent and Emergency Care Stocktake meeting on 8 October 2019 - a
go live date of 4 November 2019 was agreed to allow time for joint staff briefings which are underway.
A meeting between the EMAS and Leicester Royal Infirmary Chief Executives, Directors of Operations, Directors of Nursing/ Quality and Medical Directors took place on 17
October 2019 to discuss the feasibility of implementing a Rapid Handover Protocol, work is now underway to look at how the protocol will need to be amended for use in the
Leicestershire system.
Discussions have commenced with the quality lead from the co-ordinating commissioner regarding a system wide process for assessing harm due to prolonged delays
Additional control relating to Private Ambulance Service resourcing added by Risk Owner – November 2019
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Additional mitigating action relating to Incentive Scheme added by Risk Owner November 2019
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Document Outline