Annual report 2012-13 - West London Mental Health NHS Trust

5. Reviewing the effectiveness of riskmanagement and internal controlThe trust’s risk management arrangements have beeneffective, enabling the trust to identify potentiallysignificant risks at an early stage and take suitableaction to either prevent those risks developing furtheror, if necessary, control those risks.In February 2013, the trust was assessed as complyingwith level 1 of the NHS litigation authority (NHS LA)risk management standards, the trust complying withall 50 of the risk management standards.RSM Tenon, the trust’s internal auditors, hasjudged the trust to have a risk maturity statusof ‘risk managed’. This provides independentevidence of the robustness and effectiveness of thetrust’s risk management arrangements. This is anotable improvement compared to last year, whenthe trust was judged to have ‘risk defined’ status.The trust is working towards achieving‘risk enabled’, the highest level possible (seetable below).In carrying out audits across the trust, the workof internal audit provides assurance on theeffectiveness of certain risk controls. Where thoseaudits reveal areas for improvement, these are fedback to the service manager concerned and theCSU director so suitable action can be taken.In order to confirm that the trust has effectivesystems in place which link clinical audit to theboard’s assurance framework an advisory review ofclinical audit was undertaken by the trust’s internalauditors during 2011/12. This concluded that theIncreasing risk maturitytrust has taken active steps for ensure that its clinicalaudit function is in line with identified best practice.The medical director commissioned an externalreview of the trust’s clinical governancearrangements which assessed the trust against thequality governance requirements for foundationtrusts. The review was undertaken by KPMG. Thisfound that the trust has invested significantly instructures and processes designed to ensure that thequality of clinical services can be defined, measuredand reported both openly and clearly. The reviewidentified certain areas for further developmentwhich are in the process of being addressed.External assurance was provided on aspectsof the trust’s quality account for 2011/12 byPricewaterhouseCoopers LLP.Clinical risk managementThe trust in accordance with NHSLA requirementsfor biennial review was re assessed against theNHSLA standards in February 2013. The trust wassuccessful in retaining the mental health NHSLAlevel 1 standards. The director of nursing andpatient experience has responsibility for NHSLAand performance monitoring is undertaken by thetrust management team meetingThe trust’s complaints policy is in line with theNational Health Service (complaints) regulations. Thesystem of managing complaints is reviewed by thequality committee to ensure that improvements incare as a result of complaints are evident. There isnow an improved process in place for managementand learning from complaints. Compliance with thetimescales for responding to complaints is reportedAware Defined Managed EnabledInformal approachto risk managementRisk managementapproach adoptedto meet basicexpectations ofstakeholdersRisk managementapproach built intonormal businesspracticeRisk managementsupports the deliveryof strategic aimsmonthly to the board. Internal audit providedpositive assurance over these processes.The trust has an electronic incident reportingsystem throughout the organisation for reportingall incidents, including “near misses”. A summaryof “complaints, incidents and claims” is presentedto the quality committee to ensure that issuesidentified are shared more widely.Infection control & registrationThe trust continues to implement its infectioncontrol action plan which is overseen by the trustwideinfection control group and reported to thepatient safety and safeguarding sub committee.An annual report is submitted to the qualitycommittee. Monthly audits are undertaken andactions implemented accordingly.Finance, resources & environmentThe trust has a robust system to maintain regularoversight of its financial position. This includes thefinance & investment committee.As an employer with staff entitled to membershipof the NHS pension scheme, control measures are inplace to ensure all employer obligations containedwithin the scheme regulations are complied with.This includes ensuring that deductions from salary,employer’s contributions and payments in tothe scheme are in accordance with the schemerules, and that member pension scheme recordsare accurately updated in accordance with thetimescales detailed in the regulations.Control measures are in place to ensure that all theorganisation’s obligations under equality, diversityand human rights legislation are complied withand this is led by the equalities steering groupwhich reports through the clinical effectiveness andcompliance committee into the quality committee.The trust continues to undertake risk assessmentsin accordance with emergency preparedness andcivil contingency requirements (based on UKCIP2009 weather projections) to ensure it meets itsobligations under the Climate Change Act andthe adaptation reporting requirements. Businesscontinuity plans (BCPs) include heat wave andsevere weather episodes. The BCP annual reviewprocess captures flood events at applicablesites and acknowledges and addresses the risksthat climate change poses to the continuedfunction and performance of the trust. Capitalredevelopment projects consider the impactsof climate change on drainage and flood riskmanagement strategies.Carbon reduction delivery plans have beendeveloped to cover trust buildings, transportand travel, procurement and other key areas.These are in the process of being implementedfollowing the approval of the trust’ssustainability strategy in 2011/12.CapitalThe trust has two major capital redevelopmentprojects, one relating to Broadmoor Hospitaland the other to the redevelopment of our StBernard’s site in Ealing, that present an area of riskin terms of capital resources and delivery. I gainassurance that risk is adequately managed throughthe programme boards, one of which I chair(Broadmoor) and the other which is chaired by thedirector of finance / deputy chief executive. Bothprogrammes have reported to the trust board on aregular basis in 2012/13.The trust received an advisory audit on the StBernard’s redevelopment programme in 2012/13.The audit had an overall rating of “green” andcontained no recommendations. Procurementand compliance with standing orders was also thesubject of an advisory audit and had an overallrating of “amber/green”, with 6 medium priorityand 1 low priority recommendations which will beimplemented in 2013/14.48 Annual Report 2012/201349