Item 8 - Sheffield Health and Social Care

13.3.3 Learning from Good PracticeThe Trust utilises a number of methods for ensuringthat good practice and lessons learned are sharedacross the services. These include:• Utilising clinical audit/clinicaleffectiveness reports• Quality Improvement Group• Staff and service user surveys and thedissemination of results• Reports of compliments received and thelearning from complaints, incidents and claims• Improving quality events• Quality check meetings;• Team and directorate governance reportsand events• Inpatient Forum (formerly Acute Care Forum)• Community Care Forum• Service User Safety Group• Sharing Good Practice events• Making contributions at conferences• Risk Register Leads meetings.A key learning point from incidents reported in theperiod is ensuring that service users’ families andcarers are involved in care planning and decisionmaking. The Trust is continuing to improve recordkeeping to ensure comprehensive and timelyrecords are made. Communication between NHSprofessionals also needs to be strengthened to ensureinformation is shared appropriately.Learning is also shared through the Service UserSafety Group, as well as through a variety ofcommunications, for example Risk ManagementUpdate and Litigation News. As Chief Executive, Isend out a monthly letter to all staff, which includesreferences to good practice and achievements thatthe Trust has identified.The Trust’s annual Quality Accounts provide abalanced view of the Trust’s performance onquality issues.13.4 The Risk and Control Framework13.4.1 Risk Management StrategyThe Trust recognises that positive and managedrisk taking is essential for growth, developmentand innovation. ‘Risks’ are not seen as barriersto change and improvement; instead they arerecognised, considered and managed effectivelyas part of improvements.The Trust’s Risk Management Strategy, which wasrenamed and revised during 2012/13 and ratified inMarch 2013, is shared with new staff at induction,handed out at training courses and is available onthe Trust’s intranet and internet sites, together withother policies and procedures to inform practice.The Risk Management Strategy describes:• The Trust’s vision, values, attitude and strategicapproach to safety and risk management;• The Trust’s structure and governancearrangements for safety and risk management;• Roles, responsibilities and accountabilities forsafety and risk management;• The risk assessment and management processes;• Key components of risk management, namely:– Board Assurance Framework– Risk Registers– Incident and Serious Incident Reporting– Identification and analysis, controland monitoring,– Learning and sharing learning from Incidents,Complaints and Claims;• Staff Learning and Development• Involving Service Users and Carers;• The Trust’s operational approach to riskmanagement;• Using evidence-based practice;• Using information effectively.Other policies related to the effective assessmentand management of risk are available to all staffvia the Trust intranet and internet sites and arereferenced in the Risk Management Strategy.A system is in place to prompt the review andrevision of policies as required.13.4.2 Risk Assessment and Monitoring SystemsIdentifying and managing risk is embedded in theactivity of the organisation through the governancestructure. This includes service governance withineach of the service directorates and agencies, andteam governance in all clinical teams. Each teamproduces a report at least annually, for directoratereview. All Directorates are reviewed through aregular performance review with the Executive Team.Risks to achieving the Trust’s corporate objectivesand risks to the viability of the Trust are recordedand monitored through the Board AssuranceFramework, which is linked to the broader Trust(Corporate) Risk Register. All risks are assessed usinga stepped approach which identifies and analysesthe risk, identifies the control measures in placeand how effective these are and the actions thatneed to be taken to reduce/mitigate/remove therisk. Risks are graded according to their severityand likelihood of recurrence, using a 5 x 5 riskgrading matrix based upon guidance produced bythe former National Patient Safety Agency. All risksthat are categorised as moderate or high (scoring12 or above) are entered onto the Corporate RiskRegister, together with all risks that are categorisedas cross-Trust risks, for example, information riskswhich affect more than one directorate. Risks arerecorded on the Ulysses Safeguard system which isan electronic database with sub sections for eachdirectorate. Within directorates, individual teamsor departments also have their own sub-sections.All recorded risks have an accountable individualand are reviewed and monitored by the appropriateoperational governance group.Directorate Risk Registers are reviewed as part ofthe service review process to ensure that they are‘live’ and being managed effectively and efficiently.Each directorate has a risk register lead who isresponsible for reviewing and maintaining their riskregister. The Corporate Risk Register is administeredby the Risk Register Co-ordinator, who also providesadvice, support and guidance for the directorate riskregister leads.All high level risks are reported to the ExecutiveDirectors Group and the Board of Directors monthlyusing a Board Risk Profile. The Corporate RiskRegister is reviewed and reported to the ExecutiveDirectors’ Group, the Quality Assurance Committeeand the Audit and Assurance Committee quarterly.Risks are also highlighted via feedback from incidents,including serious incidents, complaints, concerns,claims and other queries. The Executive Directors’Group, Clinical, Service and Support Directors receivea monthly overview of all on-going serious incidents.Directorates also receive monthly reports on theirown incidents..The Quality Assurance Committee of the Board ofDirectors and directorates receive quarterly reportson incidents and complaints which analyse thedata from these sources for any trends and issuesidentified. National benchmarking information fromthe National Patient Safety Agency (responsibilitiespassed to National Commissioning Board) is usedto understand and interpret the Trust’s incidentreporting patterns. The findings of external inquiriesand national reports are also shared and acted uponas described in the Trust’s National ConfidentialEnquiries Policy.13.4.3 Board Assurance FrameworkThe Board has an approved Board AssuranceFramework for the period 1st April 2012 to31st March 2013, which was last approved by theBoard in March 2013. The Assurance Frameworkis based on the Trust’s strategic aims, as describedin the Annual Business Plan, and the corporateobjectives derived from these strategic aims. TheBoard Assurance Framework was further developedthis year to take into account recommendationsfrom Internal Audit reports. Key high level andcorporate risks identified through risk registerswere incorporated during the development ofthe Framework.Implementation of the actions in the BoardAssurance Framework is monitored through theExecutive Directors’ Group. The Framework isup-dated and reviewed quarterly by the ExecutiveDirectors’ Group and the Audit and AssuranceCommittee and bi-annually by the Board.As at 1st April 2013, there are no high level risksrecorded on the Assurance Framework. There are,however, a number of risks graded as moderate orbelow. The Board Assurance Framework recordsrisks associated with the achievement of the Trust’sstrategic objectives and acknowledges and identifiesareas where improvements are required. However,none of the areas identified are deemed to besignificant or pose a serious risk to the effectiveness139140