Annual Report and Accounts 2012/13 - Royal Devon & Exeter Hospital

4. Our Governance
Royal Devon and Exeter NHS Foundation Trust
Annual Report and Accounts 2012/13
95
Risk Register contains the
higher-level risks and Trust-wide
risks. This ensures that risks are
identified, managed and escalated
appropriately at all levels of the
organisation. Risk assessments,
including Health and Safety and
Infection Control are undertaken
throughout the Trust. All areas
of the hospital have trained Risk
Management Officers and the Risk
Management Department and
Head of Governance facilitate risk
surgeries to provide support and
training and to ensure consistency
in approach.
5.5 Other methods to identify risks
include:
• Complaints, Care Quality
Commission and Health Service
Ombudsman reports and
recommendations
• Inquest findings and reports from
HM Coroner
• Health and Safety Executive and
regulatory body compliance
inspections
• Medico-legal claims and litigation
reports
• LiNKs and Health Scrutiny
Committee reports
• Incident reports and trend analysis
(via Datix software, identification
of hot spots)
• Internal and external audit reports
• Quarterly Performance Reviews
• Feedback from Governors and
Members
• Ward to Board Framework, Clinical
Quality Assessment Tool (CQAT)
• Safety Thermometer.
5.6 Information Governance and
data security is managed by
the Information Governance
Steering Group lead by the
Director of Finance and Business
Development, the Trust’s
nominated Senior Information Risk
Owner. Information Asset Owners
for critical systems have been
identified; system risk assessments
and Information Risk Management
training is undertaken annually.
5.7 An Information Security Forum,
chaired by the Medical Director
as Caldicott Guardian, deals with
all aspects of information security
and data confidentiality. Risks to
information security are reported
directly to the Information Security
Forum (a sub-group of the
Information Governance Steering
Group) and recorded on the
Corporate Risk Register. The Trust
has completed the Information
Governance Tool Kit assessment
and the Audit Committee and the
Board of Directors has received
a report regarding its system for
control of Information Governance.
5.8 The Trust is green-rated on the
Information Governance Toolkit,
achieving a level 2 on all 45
requirements.
5.9 Control measures are in place to
ensure that all the organisation’s
obligations under equality, diversity
and human rights legislation are
complied with. As a public sector
organisation, the Trust has legal
obligations as regards equality and
diversity through both the Equality
Act and the Public Sector Duty.
5.10 The Board of Directors receive
assurance that we are meeting our
legal obligations with regard to
equality and diversity, through an
annual report received, on behalf
of the Board of Directors, by the
Governance Committee.
Full evidence of legal compliance
is also published on the Trust's
external website.
The Trust uses an NHS-designed
tool, the Equality Delivery System
(EDS), to ensure compliance with
legal obligations and enable
continuous improvement.
5.11 As an employer with staff entitled
to membership of the NHS Pension
Scheme, control measures are
in place to ensure all employer
obligations contained within the
Scheme regulations are complied
with. This includes ensuring that
deductions from salary, Employer’s
contributions and payments into
the Scheme are in accordance
with the Scheme rules, and
that Member Pension Scheme
records are accurately updated in
accordance with the timescales
detailed in the Regulations.
5.12 The Trust has undertaken risk
assessment and Carbon Reduction
Delivery Plans are in place in
accordance with emergency
preparedness and civil contingency
requirements, as based on UKCIP
2009 weather projects, to ensure
that this organisation’s obligations
under the Climate Change Act
and the Adaptation Reporting
requirements are complied with.