5 Boroughs Partnership NHS Foundation Trust Annual ... - Monitor

Directors attending the Trust Operational Performance Team meetings review
high-level risks monthly and in further detail at the Clinical Governance and
Clinical Risk Committee, which is a sub-committee of the Trust Board.
During 2011/2012 developments have taken place to integrate reporting of the
Trust Risk Register and the Assurance Framework. Since October 2011 the
Trust Board has received an integrated Assurance and Risk Report. This now
provides the Trust Board with a joined-up Risk Management Report to fully
consider the risks to achieving the high-level objectives.
The Trust’s main risks as set out in the Trust Risk Register in year are:
The Trust raised a high-level risk in relation to demonstrating compliance
with Care Quality Commission Essential Standards of Safety and Quality.
The Trust has a system of continual compliance in place that involves
scrutiny by the Clinical Governance and Clinical Risk Committee. Through
Internal Systems of Control the Trust identified areas of improvement
around policy to practice. The Trust has implemented an annual
programme of internal inspections aimed at testing practice in line with
CQC standards. The internal inspections will be integrated into the existing
compliance cycle
During 2011/2012 the Trust reviewed its Serious Untoward Incident
Review process with a focus on further improving the quality of the
reviews. This has included commissioning of a 72-hour review to inform
and set the Terms of Reference for the review to ensure critical questions
are set and a focused timeline is established. In addition further quality
assurance steps have been included in the process. The Trust has raised
a risk relating to the timeliness of completion of the reviews in line with
National Patient Safety Agency Guidance
The Trust has taken steps to integrate the Risk Register and the
Assurance Framework throughout 2011/2012. KPMG completed a review
of the Risk Management and Board Assurance Framework in March 2012
with an outcome of substantial assurance. Areas of best practice were
identified by KPMG and the Trust is working to further develop and
integrate the Risk Register. A risk has been raised and mapped to the
Trust Objective to incorporate the identified areas of best practice.
Risk movement and control is monitored monthly at the Trust Operational
Performance Management meetings, where accountabilities for risk control
and risk movement are discussed. The operational groups for managing risk
are the Trust Management Team (Quality) and the Corporate Quality,
Performance and Risk Forum, which receives a monthly Safety and Quality
Metrics Report.
Annual Report and Annual Accounts 2011-12 159