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 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