5.1B Corporate Risk Register

1. STAFFING Debbie Eyitayo

Capacity and ability of senior Controls • Development and delegation to deputies Daniel Elkeles leadership teams to •Board and Exec support for guidance on relative priorities where possible • Introduction of efficiences through the delivery of various transformation schemes deliver all of the trust's operational, •Clarity on Executive Team Objectives and Team Roles •Further careful review of trust' s corporate priorities at Executive Level and at Board and Board quality, patient experience, •Quarterly Team Performance Review Meetings sub-committees, and in- year additional pressures or projects behaviour and culture programme, • Adjusted Executive portfolios including additional Deputy Chief Executive role established with a focus on operational issues. Director of Corporate Appropriate follow through of issues which staff raise financial, strategic objectives, Services role established and Director of People appointed. Fully develop and implement action plan from External Well Led Review to agreed timescales including significant infrastructure Appointed substantive Director of Integration projects and developing wider • Additional Non-Executive Director with a focus on integration in post partnerships for community services. •Progress being made on backlog in responding to complaints with agreed timescales. New processes being introduced, including dedicated named complaints support staff for each division 1.1 20 16 • The most serious incidents are being handled and managed appropriately , and new processes being explored for reviewing lower level incidents. 20 20 Apr-16 Aug-19 Sep-19 Strengthened resources to deliver the estates and intrastructure projects, with close involvment of relevant Execs and divisional teams to agree plans and ensure delivery Launched Your Voice, Your Values Cultural Engagement Programme Implementation of Well-led review recommendations underway Assurances Where and when reviewed ; Monthly Divisional Meetings, Weekly Exec Review on Medical and Nursing staffing, POD, PSQ and Board.

Medical Staffing Shortages impact on Controls Further controls required James Marsh/ service Daily review of medical rota gaps, rota management within Division with senior local clinical input, temporary staffing booking systems and controls. Sign off Medical recruitment plan; introducing alternative staffing models such as Physician's Debbie Eyitayo quality and financial performance of all above CAP bank and agency booking by Medical Director; re-deployment of permanent staff to cover gaps; escalated bank and agency rates to cover Associates, Advanced Nurse Practioners; re-design of medical rotas; service improvement gaps, Consultant Acting Down cover arrangements , policy and payment mechanisms; locum and bank recruitment to cover gaps; active management of leave interventions to change models of care or reduce the demand for impatient medical staffing ; re- exception reporting to improve the junior doctor experience ; Guardian of Safe Working; medical staffing dashboard reviewed monthly by divisions and configuration of services and move to single acute site to reduce double - running of medical Executive Sub-groups; medical staffing manager appointments, medical recruitment tracker; temporary Consultant cover arrangements. rotas Assessment of sustainability of the six core acute specialities until such time that there is certainty about future trust configuration Specific Services most affected : Paediatrics , Emergency Department ,General Medicine, Epsom 1.2 16 Job Planning review to include demand and capacity assessment and combined input from 12 6 3rd July 2018 Aug-19 Sep-19

clinical lead and manager before further sign off by Clinical Director and Medical Director

Assurances Development of Critical Outreach Service to support our most acutely unwell patients. Where and when reviewed ; Weekly review of bank and agency hours ; daily review by Medical Director of all requests for Bank and Agency over London Cap rates Monthly Divisional Meetings, Weekly Exec Review on Medical and Nursing staffing, POD, PSQ and Board. Quaterley Board report from Guardian of Safe Working Practice

Nursing Staffing shortages impact on Controls Further controls required Arlene Wellman service quality and financial Review of safecare rostering system has taken place, use of appropriate RAG rating being implemented and increased availability of red flag triggers. These will Patient flow improvements to reduce demand for in-patient nursing resourtces; Growth of nurse Debbie Eyitayo performance be included in the monthly Board performance report. apprenticeships and nurse associates. Daily 0830 nurse staffing meeting on each site including use of safe care, led by senior nurse, each Friday planning meeting for weekend New recruitment strategy with SW London. Matron on each site early and late shift 7 days a week with remit to review staffing Escalation process for safety and staffing review if opening escalation areas Safe staffing policy. 6 monthly establishment review implemented which will be reported to the Trust Board in September 2019 Enhanced care policy reviewed 1.3 20 Weekly meeting with e roster and bank staffing/Deputy Chief Nurse to review e roster use, temporary staffing use and process 12 6 Aug-19 Sep-19 Establishment reset to commence April 2019 Weekly agency paid - CFO Recruitment and retention plan developed, of Lead recruitment and retention nurse, recruitment and on boarding of student nurses qualifying in September 2019. Review and introduction of new skill mixed roles (eg, pharmacy technician, nursing associate, associate practitioner with revised remit). Assurances Where and when reviewed ; Monthly Divisional Meetings, Weekly Exec Review on Medical and Nursing staffing, POD, PSQ and Board). Nursing Midwifery Committee Trust Board-monthly performance report and establishment review 6 monthly Staff with protected characteristics Controls Debbie are not treated equality or included Equality, Diversity & Inclusion Manager; Equalities action plan; Eyitayo/Arlene which impacts on service through Equality, Diversity &Inclusion Committee led by Non-Executive Director; Wellman staff failing to raise concerns or Compliance with statutory equalities duties; BME staff network ; maternity service improvement programme; review of HR processes and practices; nurse Further controls required realise their full potential for the progression programmes BME and Gender representation for all Band 6 and above recruitment panels Appointment and progression of staff with protected characteristics into senior roles; staff training and benefits of patients Your Voice Your Values Engagement Programme launced end of March 2019 development in equality , diversity and inclusion ; growth of staff network 19th August 28th Oct 1.4 16 Embedding work on new value of 'Respect' throughout the Trust 12 4 3rd July 2018 Introduction of EDI Staff Networks 2019 2019 Assurances Where and when reviewed ; Monthly Divisional Meetings, Weekly Exec Review on Medical and Nursing staffing, POD, PSQ, PARC, EDI and Board.

Staff engagement and /or confidence Controls Further controls required Debbie Eyitayo / is so low that it impacts on service Datix system ; management development programmes; streghtened Freedom to Speak Up Guardian service; divisional listening events; Trust wide and divisional staff management and leadership development ; improve staffing levels; Lisa Thomson quality through staff failing to raise communications and bulletins; divisional staff survey action plans; plans developed from outcomes from GMC Survey targeted interventions with departments scoring low in concerns or whistleblowing staff survey; BME staff network, maternity development programme, plans developed from outcomes from GMC Survey, staff FFT, Quaterly Staff Pulse Survey externally or work to their full Your Voice Your Values Engagement Programme launced end of March 2019 potential or behave in the best Assurances interests of the patient Where and when reviewed ; Monthly Divisional Meetings, Weekly Exec Review on Medical and Nursing staffing, POD, PSQ, EDI and Board. 1.5 16 12 4 01-Aug-19 Sep-19 Current End of FY Original Final Target Date added Date of Last Date of Next Risk Number Risk Name Risk Existing Controls/Mitigations /Assurances Long term Mitigating Action Plan Risk Owner Target Risk Rating Risk Rating to register Review Review Rating risk rating Ruth Charlton 2. VARIABILITY IN QUALITY OF CARE

Delays due to suspension of out of Controls Further controls required James Marsh hours • Interventional Radiologists will ensure known patients requiring interventional procedures are prioritised and not delayed into the evening or weekend hours Work underway across South West London to ensure a sustainable service going forwards. Due for interventional radiology • Emergency patients requiring a procedure out of hours will need to be transferred to St George's Hospital or another specialist centre agreement later this year , when risk should be de-escalated. Policy for safe transfer and managment of Assurances cases out of hours to be agreed by St George's Hospital MD Reviewed regularly at Clinical Services Performance Meeting, RADAH committee. Protocol developed to manage common clinical scenarios in Renal, GI Bleeding and Obstetrics (agreed internally, but awaiting sign off from St George's) Further assurances required 2.1 20 16 Active workstream through the SW London Acute Provide Collaborative to focus on optimising this pathway None identified 8 8 Apr-16

Ability to maintain service Controls Further controls required Dan Bradbury consistently Close management of patients requiring review in place A trust strategy for cardiology service required to ensure consultant review of patients 7 days a week and including timely access to non- Renal patients - Dialysis on an inpatient ward. For those patients of known risk, this should be monitored in a HDU setting, which is not always available while expediting which specific sub-specialties are appropriate. elective and elective care in transfer to St. George's. Locum consultant currently being sourced to ensure additional support is in place. Cardiology due to fragmented Assurances Further assurances required 2.2 pathways and insufficient medical 16 16 Regular review at Executive level. None identified Dec-16 cover, and for renal patients requiring cardilogy intervention at St Georges or monitoring capacity in St Heleir HDU Patient safety and organisational Controls Further controls required Arlene Wellman reputation may be compromised due IPC Head of Nursing full site More awareness and standardisation of practice across the Trust is required in terms of management of to the number of C Diff, MRSA cases IPC ward champion relaunch with key roles and time aside to attend fora and to undertake infection control practice training and audits. (implemented) diarrhoea. An amended C diff policy has been written and this will be taken to the Infection Prevention & identified as being hospital acquired Control Committee for approval on the 23rd of October. Assurances All IPC polices are due for renewal and the team is in the process of reviewing and updating all policies. IPC action plan of work monitored through IPCC and quarterly with CCG at CQRG. On monthly IPR and reviewed in depth by DIPC , PSQ Review of hand hygiene products and signage. Back to basics on hand gel and hand washing . Review 2.3 16 16 placement of gel dispensers to include entrances as well as end of beds. (implemented) 8 0 Feb-17 Monthly review of performance for hand hygiene to concentrate on 100% of areas undertaking 5 moments audit.

Further assurances required None identifiedFurther controls required

There has been a significant increase Controls Further controls required Arlene Wellman in child Current highest concerns within the provision of services include: Surrey CAHM’s engagement to continue to to provide service which mirrors Sutton & Merton. safeguarding activity, including Capacity to deliver Safeguarding supervision to Trust Staff. children presenting with self- Staff often have to cancel attending safeguarding training. Also staff are often unable to provide supervision due to other clinical responsibilities. The Safeguarding Team harming behaviour, across the Trust does not always have the capacity to provide additional supervision and therefore there may not be the appropriate oversight of cases of concern. and resulting in challenges in CAHMS Laision and bed accessing reviewed providng the best possible services Childresn Safeguarding review by external company and support for them. Assurances Weekly monitoring of all paediatric attendances by Head of Nursing to the Chief Nurse Monitoring at Safeguarding meetings 16 16 0 0 Jan-19 Aug-19 Sep-19 2.4 Regular review at the Women and Children Governance Meetings Supervision is reported to the CCG as part of a Dashboard Regular sharing of information with CCG's, Sutton, Merton and Surrey Councils and Mental Health Service providers.

Adequate care for CAMHS patients Controls Further controls required Arlene Wellman who attend ED or are admitted to a Use of CAMHS/pyschaitric liaison services (24/7 only at STH); use of RMNs and additional support where required (such as HCAs or security) System-wide response to CAMHS capacity to meet demand ward while waiting to access to Use of escalation protocols for delays in assessment CAMHS services Assurance Visibililty of patients on sitreps and review on calls Reviewed at WACS and medicine goverance meetings (for ED)Review/deep dive at PSQC Urgent Discussions between Clinical Directors 2.4a 20 - Casey Ward Jun-19 Impact of lack of RN and CAMHS 24 hour assesment plus tier 4 beds RNS establishment ED and Casey Individual assessment and implementation of enhnced care policy

Out of hours we do not consistently Controls Further controls required Joint Medical have Further use of technology for identifying deteriorationg patient (Vitalpac across all areas with implementation of NEWS 2) Evaluation of new CC Outreach Team at STH and start at Epsom Directors/Arlene adequate senior oversight of the Increased consultant cover on site at STH in the evening Consideration of electronic tools for handover Wellman acuity of our inpatients, potentially Strengthened leadership of Hospital at Night (H@N) leading to delays in escalation and Implemented bleep policy Late Senior Nurse rota handing over to Hospital @ Night timely treatment of any medical Strengthened handover arrangements Review of H@N operation deterioration Review of use of available medical resource Senior Nurse Rota (Off site ) to provide advice and support to junior staff Critical Care Outreach Team at STH went live on 15.04.2019 08.00 to 20.00 7/7 Assurances Further assruances required Close Executive review, and monitored through RADAH; Job planning to ensure enhanced medical consultant presence in the twilight hours, monitoring of mortality reviews Assessment of sustainability of the six core acute specialities until such time that there is certainty about 2.5 15 15 future trust configuration 12 8 Apr-17 Current Original End of FY Final Target Date added Date of Last Date of Next Risk Number Risk Name Risk Existing Controls/Mitigations /Assurances Long term Mitigating Action Plan Risk Owner Target Risk Risk Rating to register Review Review Rating risk rating Rating/Date Delays in the timely production of Controls Further controls required Dan Bradbury patient Additional project management capacity introduced, working closely with clinicians, clinical adminstration teams, IT, procurement and the service provider to resolve. Close Further steps to be reviewed if performance does not improve sufficiently. letters. This includes including monitoring of backlog of letters. Technical issues being resolved leading to improvments in service, but further work required to ensure robust service is established with all CDs to work with Directorates to improve peformance providing information to GPs due to users confident in use. Further assurances required internal process issues which might Assurances None identified 2.6 cause patient harm if medication 15 15 Reviewed regularly by COO 0 0 May-17 changes are not communicated within required timescales

The Trust is not achieving the Controls Further controls Dan Bradbury RTT threshold of 92% across a • Cancer patients managed separately The reviewing of pathways and theatre lists number of specliaties, meaning some • Redesign of patient pathways e.g. Virtual reviews Further assurances required patients are not being treated within • Additional lists to create capacity timescale, which could mean delayed • Patient tracker lists given daily and weekly scrutiny diagnoses and treatment and cause • Operating plan trajectory agreed with Commissioners and NHSI to deliver the standards we have been set for 2018/19. harm to patients. Assurances • Weekly meetings with Director of planned care to discuss issues and define plans to address 2.7 15 15 •Weekly review at Operational CTM 0 0 Aug-17

Failure to ensure that appropriate Controls Further controls required procedures are in place Trust wide • Detailed investigations undertaken and remedial action taken. To be developed and are fully embed to ensure • Wider learning on WHO checklists discussed and disseminated via Quality 1/2 days. Further assurances required ‘Never Events’ do not take place. • A further Quality 1/2 day included discussion of learning from undertaking procedures in non-theatre settings to ensure appropriate formal systems and processes in place PSQ to review in more detail those areas requiring updated LOCSIPS and settings reviewed (e.g. bedside as opposed to treatment room). Individual divisions have reviewed the processes in place for all procedures undertaken in a non-theatre setting, and are implementing local protocols to ensure lessons are learned. 2.8 15 16 Review of LOCSIPS underway but not yet complete 6 0 Sep-17 Assurance Reviewed at CQAC, PSQ

There are ED flow and capacity Controls Dan Bradbury issues as a result of increased acuity Flow: Maximise the use of all ambulatory capacity, using medical ambulatory on C1 and the Surgical •Appoint the workforce matron to oversee all winter escalation ensuring right staff on duty maximised and higher demand later in the Assessment Unit on Mary Moore to draw patients out of the Emergency Department and potentially reduce the numbers of patients requiring a bed. across Trust using Safecare and to be central point of control for emergency staffing on StH site. evenings combined with niche staff - Open Escalation areas in accordance with the 2018 escalation protocol: for STH this support Frank Deas Ward (6), B5 (7), and wards C5 and B4 which are purely held for Urgent Care Board to review use of surgical ambulatory and medial ambulatory care new models to availabilty issues. Slower flow due to escalation; for EGH this supports AMU escalation (10). ensure less inpatient beds are used. bed capacity is a contributing factor - Escalate into Northey PP beds if approved by COO or Executive on call out of hours. •Embed use of electronic bed management system to ensure greater visibility of definite and potential later in the evenings. - Maintain key focus on the assurance of safe staffing of all areas, but particularly escalation areas. discharges across the sites, and identification of patients occupying specialty wards - Maintain focus on stranded patient reviews which have reduced 21 day+ patients from 182 in June 2018 to 110 in December 2018. •Hospital Director at EGH to oversee escalation and to maintain safe staffing across this area. - For 2019/20 a major length of stay CIP programme will review staffing support, processes and cross community support to make further reductions in bed occupancy. •Identify senior and junior medical staff to cover additional ward areas. - Expand B5 / Alex discharge to assess trial from April 2019 onwards supported by SHC and SDHC respectively. •Closer alignment between Surrey Downs Health and Care and Sutton Health and Care - Radiology "pull" trial for March to ensure additional portering support in high demand hours to reduce the waiting and transit time for primary diagnostics. •Oct 2018 ED demand and capacity model to be reviewed in the light of learning from winter 2018 / 19 ED ED has already recruited 3 permanent consultants bring permanent total to 13 of 16 established posts. Nursing establishment increaed for FY 2019/20 •Medium term sustainability of service needs reviewing during 2019/20 in line with trust's operating plan - Enlarged ED on each site has: STH - increased the number of RAT, ambulance offload and resus bays; EGH - created a RAT area, built a new ambulatory medical unit and 2.9 15 16 - Offer over cap rates to ensure hard to fill shifts are safely covered, particularly the second Middle Grade role overnight in STH. Trial enhanced Medical support to the 0 0 Nov-17 Medical Assessment Unit (Hub) later in the evening to provide enhanced early support to ED admissions. - Emergency Quality Improvement Programme to review internal processes including safety 2 hourly safety huddles, RAT management of patients and the use and criteria for the Clinical Decision Unit. Assurances - Executive-led oversight of patient pathways. Reviewed at F&P

Variable delivery in terms of the non- Controls Further controls required Trevor Fitzgerald emergency patient transport service • Brought service in-house from 1 April 2018 Review of service provision - in house or outsource by end of December 2018 including impacting on dialysis Strenghtened management team of service Further assurances required patients Assurances CQC Compliance review and action plan in place Now part of Directorate Governance meeting as an Agenda Item Service performance standards to be improved by increased budgets, filling staff vacancies and PSQ Approved downgrade of 15 15 Monitored closely by Director of Estates and Facilities. Reviewed monthly by CTM and PARC purchasing new vechicles 15 12 Dec-17 2.10 risk on 27/09/2019 due to improve improved quality, safety and performance metrics . Risk to be removed from Corporate Risk Register

Risk to JAG accreditation for Controls Further controls required Dan Bradbury endoscopy due to inability of local •Reviewed locally within division None required of systems to feed into the national •A capital bid has been written and applied for version 7of the Emis clinical reporting system upgrade. database. •EMISS have been made aware that we intend to purchase the upgrade and have reduced the price. Planned instalation date Sept 18 2.11 15 3 01-Jun-17 Delays in completion of Controls Further controls required Ruth Charlton Investigations of Incidents within the Careful management of backlog Recruitment of new Quality Managers Medicine Division which leads to Review of processess going forward Training of more teams able to undertake investiagtions delays in implementing learning. The recruitment process to mortality reviewer/RCA lead posts has taken place along with a workshop to redesign RCA processes with National Head of Patient Safety . No direct plans to change SI process expected changes in place that a combination of mortality reviewers and teams on the wards daily looking for incidents allows us to identify and report RCA more quickly. Pilot since 1/5/2019 2.12 20 Wide place discussion between Medicine and Quality Teams to determine required structures. Consultation Launch 10th July 2019. 03-Jul-18 The medicine division have also funded more admin resource. Compliance reported through IPR to Trust Board, TEC and PSQ.

Current Original End of FY Final Target Date added Date of Last Date of Next Risk Number Risk Name Risk Existing Controls/Mitigations /Assurances Long term Mitigating Action Plan Risk Owner Target Risk Risk Rating to register Review Review Rating risk rating Rating/Date Trust will not have sufficient Controls Further controls required Dan Bradbury supplies of immunoglobulin to treat The Trust follows DH Guidelines and demand management programme for the use of IVIg and has an Immunoglobulin Assessment Panel (IAP) through which all requests for patients IVIg are reviewed. Approval given on the basis of whether indication classified as red/blue/grey according to DH criteria. Approval can only be given by consultants from As of October 2018 NHSE have requested the establishment of sub-regional IAP. The South London panel outside the speciality making the application. Dose based on IBW. ESTH IAP has introduced further restrictions over and above those of the DH due to the impact of will be hosted by St George’s and ESTH will have a clinician and a pharmacist representative. The aim is to shortages on the Trust. This includes further restrictions to availability for “blue” indications; increasing intervals of treatment for PID patients and a requirement for the improve control of access across the sector with the first objective to reduce the use of IVIg in “grey” consultant requesting IVIg to speak to an IAP panel member for further clinical challenge. Raised awareness of shortages with prescribers with request to review long term indications (limited/no evidence base) to release supplies back into the system. patients and ensure all alternatives considered first, to retain stock for the sickest patients. To promote the availability of plasmapheresis as an alternative treatment option. Pharmacy procurement specialist manually reviewing out of stock drugs within Medicines Management Team. 2.13 16 "To follow” items identified on pharmacy JAC system and reports generated in real time at least twice a week to track orders. Pharmacy staff are trained to bring to the 07-Nov-18 attention of the pharmacy procurement lead/Medicines Management Team any items urgently required. Manufacturers and suppliers are contacted and where possible alternative supplies are procured. Guidance on alternatives given by DH. Therapeutic substitution guidance is given by pharmacy medicines information. Information on shortages where there is no direct substitute e.g. different brand is disseminated via the weekly clinical pharmacy meetings. Shortage of medicines that are used in specific areas are communicated directly to the clinical leads / directors by the Medicines Management team. Review of prescribing guidelines with specialists e.g. Immunology in relation to prescribing changes. Assurance - Monthly Performance Meetings and PSQ

There's a risk the Trust will be unable Controls Further controls required Dan Bradbury to secure supplies of medicines due Ward stock of medicines that are in short supply are recalled from the wards and held in pharmacy for to national, worldwide shortages and Raise awareness of shortages with prescribers to amend prescribing practices to retain stock for the sickest patients. dispensing for specific patients against agreed criteria. Brexit- “To follow” items identified on pharmacy JAC system and reports generated in real time at least twice a week to track orders. Conserve drugs for existing patients already initiated on treatment. Orders for drugs on allocation placed on agreed days. Review of information from pharma companies, DHSC, NHSE and other organisations relating to potential Pharmacy staff are trained to bring to the attention of the pharmacy procurement lead any items urgently required. Brexit issues. Pharmacy procurement specialist manually reviewing out of stock drugs within the pharmacy. Review of emergency medicines used within the trust and ensure there are sufficient stocks to treat a Manufacturers and suppliers are contacted and where possible alternative items are procured. patient. If not then a review of the trust guidelines must be undertaken Therapeutic substitution guidance is given by pharmacy medicines information. DHSC is working with manufacturer’s and suppliers to hold an additional 6 weeks supply of stock in the UK Information on shortages where there is no direct substitute e.g. different brand is disseminated via the weekly clinical pharmacy meetings. in the event of a “no-deal” Brexit. Shortage of medicines that are used in specific areas is communicated directly to the clinical leads / directors by the Medicines Management team. Current DHSC advice is not to stock pile as this will disrupt an already fragile supply chain. Trust Wards receive key information on medicines shortages usually via a memo or via e-update. medicines purchases will be monitored centrally and any variations will require an explanation to be 2.14 16 07-Nov-18 Review of prescribing guidelines with specialists e.g microbiology in relation to changes to the antimicrobial prescribing guidelines. provided to DHSC by the Chief Pharmacist. Identify critical medicines to allow for review of stock holding and close tracking of usage on a monthly Assurance basis Monthly perfomance meetings and PSQ

Critical Care Outreach Team - lack of Controls Further controls required Arlene Wellman Staffing Further use of technology for identifying deteriorationg patient (Vitalpac across all areas) Need to develop and implement Standard Operating Procedure for new service along with internal Increased consultant cover on site at STH in the evening Communications Plan Strengthened leadership of Hospital at Night (H@N) Consideration of electronic tools for handover Implemented bleep policy Strengthened handover arrangements Late Senior Nurse rota handing over to Hospital @ Night Review of use of available medical resource Review of H@N operation Janaury 2019 Staff recruited to service and all due to be in post from 1st March 2019. Initial plan to implement service from 08.00 to 20.00 seven days a week at STH Senior Nurse Rota (Off site ) to provide advice and support to junior staff 2.15 07-Nov-18 Assurance Monthly perfomance meetings and PSQ

Concerns relating to Blood Controls Further controls needed: Ruth Transfusion practice in the Trust - All Blood Transfusion RCAs are approved by the Lead Haemotologist for Blood Transfusion before incidents are closed. INCIDENTS Charlton/James Governance risks Updated interim paper checklist for pre-administration has now been implemented with every blood product issued. Engagement from Clinical staff and Quality Managers regarding Blood Transfusion incidents and their Marsh Clinical Director championing transfusion related RCA's with divisions to secure timely closure management including the completion of RCAs. 21.1.19 update - this has improved following support Laboratory Staff training and competency assessments reviewed. from CD but RCAs are still slow to close. Allocation of appropriate investigator within 2 days of a Laboratory IT system (Telepath) has issuing rules in place for red cells to prevent wrong group errors SABRE/SHOT Report. 21.1.19 update - this is still not happening robustly with quality teams. Prioritise Assurances Blood Transfusion incidents when graded at 3 or above regarding investigators and RCA completion. Where and when reviewed ; 21.1.19 update - these are now more visible to divisions from work done by transfusion team. Monthly Divisional Meetings, PSQ and Board Engagement from QM’s regarding BT incidents and their management. POLICIES AND PRCOCEDURES Further controls needed: Complete the review and update of the Blood Transfusion Policy. 23.1.19 update - Completed and 2.16 16 Hospital Transfusion Committee submitted for CQAC ratification 12 06-Dec-18 Review role of and divisional engagement with the Hospital Transfusion Committee to establish it as an effective forum for discussion relating to Trustwide Transfusion NPSA sampling competency – one document required throughout the Trust. 23.1.19 update - this has not issues and to enable implementation of national standards. 31.1.19 Divisions representation is better but some areas yet to engage have put forward representatives (renal, been actioned yet. medicine, paediatrics, General surgery, anaesthetics). No Chair has yet been identified. O&G and ED need to review and agree protocol regarding the management of patients in A&E requiring Anti-D. 23.1.19 update - still awaiting agreed protocol from O&G and ED. Electronic pre-administration checklist on EPMA. 21.1.19 update - This was drawn up but EPMA requires users to complete hecklist at start and end of transfusion and feedback from local NMC is this is a concern. Currently working through IT issues but due to feedback this has not been rolled out electronically. Current traceability slip is being reviewed to make larger/more robust. . Safe management of the patient with Controls Further controls needed: Ruth an unstable airway at the Epsom site INCIDENTS Charlton/James out of hours Development of a standard operating procedure for managing the emergency airway, Purchase of an emergency airway kit to cover paediatrics and adults at both acute sites Discussions with the ENT team at St George's hospital to refine the emergency airway stabilisation Marsh and communication with staff about emergency airways management protocol to ensure optimal communication Training of theatre staff in the support of unstable airways. • Discussions with St George's ENT team to strengthen out of hours support SECAMB to divert certain types of patients who are more likely to have an unstable airway to another hospital site (patients who are bleeding post-tonsillectomy and patients • Acute Provider Collaborative oversight of network approach to managing patients with unstable airways with known head and neck cancer who have received treatment at a specialist centre), 2.17 15 The on call anaesthetic consultants at the Epsom site will receive suitable targeted training. Mar-19 Escalation of discussion to Medical Director at St George's Hospital

A no-deal Brexit may impact on Controls Further controls/assurances required patient safety and operational flow, Detailed review of all potential impacts undertaken; contingency planning in place in line with national guidance including staffing, medical supplies, devices and support None identified staff well-being, and finances from external contractors and social care partners Assurance 2.20 15 15 May-19 Regular review group chaired by COO

Diagnostic capacity issues in Controls Further controls/assurances required Dan Bradbury echocardiography and MRI due to Replacement/additional equipment ordered New equipment needs to be delivered to agreed timescales equipment capacity and availability Careful management of capacity and patients to ensure patients are prioritised on basis of need/risk of harm impacting on delivering the Assurance 2.21 diagnostic standard potentially 15 15 Regular review group chaired by COO, and planned care group; oversight by F&P board subcommittee 6 6 Jul-19 delaying patient treatment

01/07/2019 30/09/2019 Current arrangements for pharmacy Controls Further controls/assurances required James Marsh and medicines management in terms Review by NHS London region's Chief Pharmacist commissioned; action plan developed; immediate action taken to strengthen executive oversight Action plan to be implemented to agreed timescales of governance, leadership, staffing Assurance structures not in line with best Regular review by Joint Medical Director; oversight by PSQ and Board 2.22 practice impacting on the 15 15 12 6 Jul-19 effectiveness of the service and use of medicines in the Trust

01/07/2019 31/08/2019 Trevor Fitzgerald 3. ESTATES & INFRASTRUCTURE Loss of provision of clinical services Controls Further controls required Trevor Fitzgerald throughout Trust due to poor • Temporary repairs/fix as and when required. condition of external buildings. • Access restricted to prevent harm (where appropriate). Long term estates strategy being pursued through Improving HealthCare Together Programme (Roofs, Windows, Walls, Structure) • Estate Strategy approved at January 17 Trust Board for priority investment to meet increased critical backlog risks. Further assurances required 12 3.1 25 20 • 5 year estates strategy addresses critical infrastructure risk. Further capital funding to address Critical Infrastructure backlog and services critical to patient safety 20 Apr-16 Aug-19 Aug-20 Assurances 2025 • Regular monitoring and reporting by Executive Director Estates, H&S committee, Capital Steering Group

Significant disruption to clinical Controls Trevor Fitzgerald services and clinical risk throughout • Employment of competent persons trained in back-up systems and providing immediate response to loss of electrical supplies. Further controls required the Trust due to the failure of the • Communication and local business continuity plans in place. • 5 year estates strategy addresses critical infrastructure risk needs to be delivered. 16 3.2 Electrical Infrastructure 20 20 Assurances Commissioing of site Electrical capacity survey - completed 20 Apr-16 Aug-19 Aug-20 2020 Regular monitoring and reporting by Executive Director Estates, H&S committee, Capital Steering Group Further assurances required Capital Investments to undertaken recommendations of survey Inability to provide inpatient Controls Further Controls required Trevor Fitzgerald services across St Helier Hospital due • Continued regular planned preventative maintenance and servicing. • 5 year estates strategy addresses critical infrastructure risk needs to be delivered to the loss of the Central Hot Water • Skilled staff on site to respond to service loss as and when required. Further assurances required and Heating System. • Monitoring of air systems within Theatres and working with Infection Control Team to mitigate any derogation from Health Technical Memorandum’s. Robust contract management of Steam Replacement Programme and removal of Critical Infrastructire 12 3.3 20 20 20 Apr-16 Aug-19 Dec-19 • Business case approved for external funding for the replacement of steam boiler plant at St Helier & Epsom plant during contract period - up to December 2020 2021 Assurances Regular monitoring and reporting by Executive Director Estates, H&S committee, Capital Steering Group

Risk to the continuity and provision Controls Further Controls required Trevor Fitzgerald of safe clinical services, due to the • Continued regular planned preventative maintenance and servicing. • 5 year estates strategy addresses critical infrastructure risk needs to be delivered loss of Cold Water and Drinking • Skilled staff on site to respond to service loss as and when required. Further assurances required 12 3.4 Water Systems or the contamination 20 16 Monthly testing of water outlets Update Risk Assessment for provision of safe water services across the Trust 16 Apr-16 Aug-19 Aug-20 of the water systems, such as Secure Capital Funding to replace old pipework and systems/plant 2021 Legionella Disease Assurances Regular monitoring and reporting by Executive Director Estates, H&S committee, Capital Steering Group There is a risk to the continuity of Controls Further Controls required Trevor Fitzgerald clinical services continuity due to the • Robust monthly servicing and maintenance of MGPS. • 5 year estates strategy addresses critical infrastructure risk needs to be delivered loss of Medical Gases Piped System. • Specialist contractor supporting the management of old and fragile plant and equipment. Further assurances required 4 3.5 20 16 16 Apr-16 Aug-19 Mar-20 Detailed review of pipe system and highlight risks to focus funding on Updated Risk Assessment of Medical Gases and Pipelines to focus Capital Funding 2021 Assurances Regular monitoring and reporting by Executive Director Estates, H&S committee, Capital Steering Group Risk to Patient and staff safety Controls Further Controls required Trevor Fitzgerald due to defects in Fire • Fire Risk Assessments for all areas – annually. • 5 year estates strategy addresses critical infrastructure risk needs to be delivered Compartmentation and Fire • Robust fire management plans. Further assurances required prevention systems. • Regular liaison with London Fire Brigade on priorities and action plan Annual Review of high priority areas for bidding towards Capital Annual Investment Plan 4 3.6 20 16 16 Apr-16 Aug-19 Mar-20 • The impact of improvements being made to fire compartmentation will be reviewed in the context of the ongoing reconfiguration works across our Hospitals, and as 2021 business as usual for future projects Assurances Regular monitoring and reporting by Executive Director Estates, H&S committee, Capital Steering Group Risk to continuity of clinical Controls Further Controls required Trevor Fitzgerald services due to the loss of critical • CCTV and visual survey undertaken on all sewage and drainage systems. • 5 year estates strategy addresses critical infrastructure risk needs to be delivered 2 3.7 Sewage and Drainage Systems. 20 16 • Action Plan in place and low cost/quick wins items being progressed. Further assurances required 16 Apr-16 Aug-19 Mar-20 2021 Assurances Annual Review of high priority areas for bidding towards Capital Annual Investment Plan Regular monitoring and reporting by Executive Director Estates, H&S committee, Capital Steering Group Current Original End of FY Final Target Date added Date of Last Date of Next Risk Number Risk Name Risk Existing Controls/Mitigations /Assurances Long term Mitigating Action Plan Risk Owner Target Risk Risk Rating to register Review Review Rating risk rating Rating/Date Risk to the loss of Theatres and Further Controls required Trevor Fitzgerald Continued regular planned preventative maintenance and servicing. Critical Clinical Areas across the Trust • 5 year estates strategy addresses critical infrastructure risk needs to be delivered • Skilled staff on site to respond to service loss as and when required. due to the failure of Air Handling and Further assurances required • Monitoring of air systems within Theatres and working with Infection Control Team to mitigate any derogation from Health Technical Memorandum’s. cooling Systems 12 3.8 20 20 Appointment of Engineer for ventilation systems 20 Apr-16 Aug-19 Dec-19 Capital funding secured for replacement of A2 Theatres (STH) and Langley and Wells Wing (EGH). Due for completion by Dec 2020 2021 Assurances Regular monitoring and reporting by Executive Director Estates, H&S committee, Capital Steering Group

Insufficiently robust delivery of Controls Further assurances required Trevor Fitzgerald sterile services to support clinical Careful management of service by service managers and theatre staff to ensure correct equipment available activity, including for off-site clinics Further strengthening of all decontamination service provision and senior management support Strengthened contract management processes Strengthened contract management processes Procurement of new service for 2019/20 Assurances Further assurances required 16 16 16 6 3.9 Regular monitoring and reporting by Executive Director Estates, H&S committee, Capital Steering Group Review current position re Risk and agree short term requirements

Increased Clinical risk and loss of in- Controls Further controls required Trevor Fitzgerald patient beds across the Trust due to • Continuation of regular planned maintenance and servicing to the lifts. 5 year estates strategy addresses critical infrastructure risk. the failure of mechanical Bed Lifts. • Essential spare parts retained on site, if possible. Review prioritisation of capital plans for 2018/19 to address lifts at QMHC, maternity at STH and Wells • Business Continuity Plans in for local clinical services. Wing and Langley Wing at Epsom 6 3.10 16 20 Short term fix in place for Wells Wing Further assurances required 20 Aug-19 Mar-20 2025 Emgergency Capital Funding approved for essential repairs Appointed authorsided engineer and consultants to review current coniditon and maintenance of lift and Assurances provide investment plan Regular monitoring and reporting by Executive Director Estates, H&S committee, Capital Steering Group Develop an investment plan to address high risk areas

There is a risk that the Renal units Controls Further controls required Trevor Fitzgerald will not be able to deliver clinical Careful monitoring and review of risks relating to all units including satalite units services to an acceptable standard Interim investment in prority repairs for Unit at Croydon New Croydon Dialysis Unit by April 2020 and meet statutory requirements Infection control audits. Reprovosion of Beacon Ward by April 2020 required under Health and Safety Incident reporting. Further assurances required 4 3.11 16 16 16 Aug-19 Mar-20 and CQC. Health and Safety inspections. Capital Funding to be secured to move inpatient provision into main block during 2019/20 and 2020/21 2021 Statutory and Mandatory training. Frequent consumable deliveries to reduce need for bulk storage. Assurances Regular monitoring and reporting by Executive Director Estates, H&S committee, Capital Steering Group Inadequate facilities for HDU/ITU at Further controls required Trevor Fitzgerald St Helier. Controls Capital Investment of £3m agred and for the expansion of the service into C2 - works expected to 3.12 20 20 Careful management of equipment and critical care bed utilisation. complete April 2020 8 TBC Assurances Further assurances required Regular executive review to be identified Aug-19 Mar-20 The Trust has prioritised divisional Controls Further controls required Trevor Fitzgerald bids for new medical equipment, but Prioritisation with all divisions to fund the most critical equipment this year £1M allocated with a £200k contingency for emergency capital bids Future capital funding bid and exploring opportunities for managed service contracts. there is a risk that limited capital Careful management of equipment and precautionary measures to minimise the impact Further assurances required funding means that not all medical Maintenance management contracts Review priority lists for funding from Charitable sources 9 3.13 equipment identified as requiring 15 15 Assurances 15 Q4 Aug-17 replacement can be replaced. Monitored carefully through Capital Steering Group monthly 2019/2020

Aug-19 Mar-20 Loss of ability to function Controls Further controls required Peter Davies effectively by not having access to •Will work into future capital plans to secure additional funds to deliver the digital strategy including digital patient data and business • Complete upgrade to Wi-Fi networks. Upgrade to wired networks ongoing. addressing long term PAS/EPR replacement data, due to aging equipment, cyber • Replace and upgrade to Windows 7-10 - to be completed by March 2020 - plan in place security incidents, and other • e-Prescribing to deliver safer prescribing and administration rollout to be finished Further assurances required 3.14 potential factors 16 16 Server infrastructure - to be identified 16 4 Storage infrastructure Network infrastructure Assurances Reviewed at monthly ICT projects review chaired by SIRO and each IG Committee and ICT Steering Group and Capital Steering Group Audit Committee reviews cyber security at each meeting Rakesh patel 4. FINANCES

Controls: Further controls required Rakesh Patel Inability to achieve long term Developing scenarios, including within the south west London STP and with regulators, to ensure long-term clinical and financial sustainability of services and addressing financial sustainability due to critical estate issues Work collaboratively with partners to identify further inefficiencies of providing range of Proposals at an advanced stage to collaborate further on pathology, procurement, and shared staff bank across SWL. opportunities for more efficient working in back office and 4.1 20 20 12 4 Dec-16 Aug-19 Sep-19 services across two 'subscale' acute Assurances clinical services sites, contributing to an increasing Reviewed by CTM, at collaboration boards, Finance Committee and Board underlying structural deficit. Further assurances required • Using benchmarking information to focus on areas of relative inefficiencies Inability to achieve control total Cost Improvement Mitigations: Further controls required Rakesh Patel through under-delivery of Cost •The Service Improvement Team has been re-focussed on fewer larger projects Further CIP need to be identified; system wide financial recovery plans to be agreed Improvement •More rigorous governance framework developed and implemented. Work collaboratively with partners to identify further opportunities for more efficient working in back Plans and inability to meet Income •Targeted expert external support commissioned office and plan within budget, or Expenditure in • Joint Financial Recovery plans for Sutton and Surrey Downs CCGs in place clinical services excess Assurance Further assurances required  of budgets •Joint recovery plans developed with Surrey Downs ICP and Sutton Place to deliver system QIPP; • Using benchmarking information to focus on areas of relative inefficiencies 4.2 20 16 12 4 May-19 Aug-19 Sep-19 •Expenditure mitigations: Aug 19 •Monthly review of budgetary underspends to convert into savings to cover unidentified CIP and unforeseen cost pressures • Governance structures in place to support effective delivery of the Programme and to quickly escalate any delays to delivery of the Programme, include: o Monthly reviews by CFO. o Biweekly executive CIP Board. Monthly review at Finance Committee.