Responsible
Directorate Nature of Risk Objectives Risk Risk Detail
Rating Impact Rating Likeli Inherent Score Curren Impact Curren Likeli Curren Score Target Impact Target Likeli Target
Score Controls Gaps in control or action required Assurances Future actions
Completion Date Handler DGC - Director of Governance and Compliance 01 - Compliance Organisational excellence R0124 - Ensuring CCG operations are compliant with Information Governance standards
On an annual basis, the CCG must demonstrate that it has implemented and maintained IG related policies, procedures and working practices to a standard necessary to achieve a satisfactory (e.g. level 2 or above) level of compliance with all requirements of the NHS Information Governance Toolkit, the Data Protection Act, the Caldicott Principles and other relevant guidance/legislation or the CCG or its staff may be subject to legal action, loss of reputation, and investigation by regulators.
4-Major 4-Likely 16 4-Major 3-Possibl e 12 4-Major
1-Rare 4 C0347 - IG toolkit compliance 13-14 C0349 - Local incident reporting and management
C0383 - Substantive Information Governance Manager
C0394 - Governing Body reports and executive updates
C0424 - End of year compliance audit
C0435 - Data flow mapping C0533 - Siro and Caldicott Guardian in post
Development of 2014/15 IG work programme and detailed milestones for Quarter 1 (April to June) – in progress
IG Compliance Audits (RSS and Children’s’ Services) to be completed during Q2 14/15 IG/ICT Security Assurance reporting schedule with CSU to be agreed during Q2 14/15 Development of network of Information Governance Champions across CCG during Q2 14/15
Interim submission of 2014/15 IGT return for CCG (non-mandatory) – 30/10/14.
Monthly review undertaken by IG Manager during 14/15 an d reported to Quality & Clinical Governance Committee . Q1/2 of 2014/15 - Independent Auditors’ review of CCG response to previously identified areas of concern and review of evidence uploaded for ICT Assurance related IGT requirements.
CCG to make full interim IGT submission in October 2014
A0091 - Draft mobile devices policy (Daniel Lo Russo, 31/10/2014, )
A0150 - Development of 2014-15 detailed milestones (Daniel Lo Russo, 02/09/2014, ) A0151 - IG Compliance Audits (RSS and Children’s’ Services) (Daniel Lo Russo, 30/09/2014, ) A0152 - IG-ICT Security Assurance reporting schedule with CSU to be agreed during Q1 14-15 (Daniel Lo Russo, 30/09/2014, )
A0153 - Development of network of Information Governance Champions across CCG during Q2 (Daniel Lo Russo, 01/04/2015, )
A0154 - Interim submission of 2014-15 IGT return for CCG (non-mandatory) – 30-10-14. (Daniel Lo Russo, 30/10/2014, ) 01/04/2015 Daniel Lo Russo DQG - Director of Quality and Safeguarding 05 - Quality To enhance quality and safety, To reduce inequalities in health R0146 - Community Provider capacity to undertake breast screening programmes
At the North West Surrey CCG Clinical Quality Review Meetings with main community provider, it has been noted that there is not sufficient capacity to meet all the service specifications for the breast screening service. The risks are physical/patient safety and reputation. The key area of deficiently is the screening service for women in the 50-70 age bracket, and not being screened at the desired frequency.
4-Major 3-Possibl e 12 4-Major 3-Possibl e 12 2-Minor
1-Rare 2 C0436 - Clinical Quality Review Meetings with Provider
C0475 - Area Team surveillance (as part of cancer strategy)
C0476 - Breast Screening Attendence to Clinical Quality Review Meeting
C0540 - Capacity Review
Cancelled meetings which are not rescheduled in month.
Clinical Quality Review Meeting with provider. National monitoring through area team. 31/07/2014 Helen Collins DGC - Director of Governance and Compliance 06 - Strategic To empower local people R0093 - Patient and public engagement activities - Listening to patients - do not effectively engage hard to reach communities
In accordance with equality and diversity: we have yet to fully engage with all our population and are yet to reach those who are deemed hard to reach. This is due to the diversity between young and old/ transient and working. There is the risk that there will be specific services that will not be provided to or accessed by specific community groups.
4-Major 4-Likely 16 3-Moder ate 3-Possibl e 9 2-Minor 2-Unlikel y 4 C0226 - Health Watch C0227 - Informal feedback from GPs, MPs, website and other qualatative sources
C0228 - Serious Incident reporting system
C0229 - Quality dashboard metrics including patient complaints C0230 - Patient Engagement Strategy
C0293 - Quality Assurance manager and Patient Engagement manager in post
C0331 - Patient and Public Engagement via Social Media
we do not have a full
demographic representation from our patients. Our new strategy will look to refresh our approach to ensure we fully engage.
We have a process in place to listen to patients: PPG-PPE group to Quality Committee We have set up digital systems and social media to enable this: website, twitter and facebook
A0035 - Review Equality and Diversity strategy and objectives (Liz Patroe, 30/09/2014, ) A0036 - Membership scheme (Paul Davey, 01/04/2014, ) A0217 - Refresh Patient Engagement Strategy with Action Plan (Liz Patroe, 15/09/2014, ) A0218 - Explore systematic capture of feedback from G&W population (Liz Patroe, 30/09/2014, )
A0219 - Explore scope for bidding for designated Heath Visitor (for traveller community) (Liz Patroe, 15/07/2014, )
Responsible
Directorate Nature of Risk Objectives Risk Risk Detail
Rating Impact Rating Likeli Inherent Score Curren Impact Curren Likeli Curren Score Target Impact Target Likeli Target
Score Controls Gaps in control or action required Assurances Future actions
Completion Date Handler DQG - Director of Quality and Safeguarding 05 - Quality Organisational excellence R0115 - Care Homes and Quality Concerns - admissions to acute
There are quality concerns related to possible inappropriate admissions into the acute trust quality, safety, reputation which may cause patient and family distress
4-Major 4-Likely 16 3-Moder ate 3-Possibl e 9 2-Minor 2-Unlikel y
4 C0271 - Risk Stratification of Care Homes- Care Home Project Group- Safeguarding Nurse-adults C0389 - Surveillance of A&E admission data and SECAMB C0537 - Intelligence from weekly BCF HIG
Data remains difficult to collect given HRG coding and coding of patient details (own homes versus care home details). Work with care homes continues Training and Development gap- work will need to develop in this area
Hard data (BI) Soft data from A&E Working with care homes in accordance with risk stratification and data intelligence Sighted by Designate Safeguarding Nurse and Quality team
A0085 - Audit of data (Helen Collins, 30/06/2014, )
A0216 - Set up care home forum (Victoria Stobbart, 31/10/2014, ) 30/11/2014 Victoria Stobbart DGC - Director of Governance and Compliance 05 - Quality Organisational excellence R0142 - Organisational culture - cross cutting ownership of corporate management areas and compliance with deadlines
To prevent non compliance with deadlines and ensure high quality submissions, corporate ownership and deadlines for cross cutting work needs to be strengthened eg. Strategy, Operational, Annual Reports; : FOIs, Complaints, Invoices, Mandatory training, Minute taking and providing cover; QIPP and information governance 3-Moder ate 5-Almost Certain 15 3-Moder ate 3-Possibl e 9 3-Moder ate 2-Unlikel y
6 C0388 - Director for Governance and Compliance
C0398 - OD workshops C0446 - Protected time - 2 hours-week to address these areas C0447 - OD and HR strategies and plans
C0448 - Flexible working
Gaps in control - whether the process of achieving compliance with deadlines is smart and effective.
Central guidance, including LAT, neither timely or clear
All submissions complied with GB and Committees with oversight
Local Area Team Q4 assurance letter
A0079 - Staff survey (Toni Downer, 31/08/2014, ) A0212 - Review relevant policies and procedures (Samantha Chalmers, 31/08/2014, ) A0213 - Training needs analysis (Toni Downer, 12/09/2014, ) 01/04/2015 Elaine Newton CFO - Chief Finance Officer 02 - Financial A sustainable health economy R0159 - Uncertainty around future viability of CSU has adverse impact on CCG sustainability
Impact on overall running costs, and service delivery 3-Moder ate 4-Likely 12 3-Moder ate 3-Possibl e
9 0 C0492 - CSU liaison meeting on a monthly basis
C0493 - Key Performance indicators on the contract
A0177 - Close monthly monitoring of the CSU contract through performance meetings (Vicki Taylor, 30/06/2014, ) Karen Mckinley DGC - Director of Governance and Compliance 06 - Strategic Organisational excellence R0167 - Collaborative approach to handling external media enquiries
If we are unable to coordinate collective, consistent responses to media enquiries across Surrey CCGs, there is a risk that individuals and organisations could be implicated before appropriate legal proceedings and outcomes had been identified. This could represent a reputational risk to the organisation and a professional risk to our members. There could also be financial implications, for example legal fees required if cases needed to be taken to court. 4-Major 3-Possibl e 12 3-Moder ate 3-Possibl e 9 3-Moder ate
1-Rare 3 C0548 - Quality monitoring C0549 - Structured teleconferences with partner organisations
A0225 - Draft templates and protocols to ensure
understanding and consistency (Paul Davey, 31/12/2014, )
Responsible
Directorate Nature of Risk Objectives Risk Risk Detail
Rating Impact Rating Likeli Inherent Score Curren Impact Curren Likeli Curren Score Target Impact Target Likeli Target
Score Controls Gaps in control or action required Assurances Future actions
Completion Date Handler DOCC - Director of Clinical Commissioning 05 - Quality To empower local people R0154 - Potential significant change to children's respite service (Beeches)
There is a high level of service user concern about potential closure. Risk around clarity of consultation and governance arrangements for decision making accross 6 CCGs.
4-Major 3-Possibl e 12 3-Moder ate 3-Possibl e 9 2-Minor 3-Possibl e 6 C0512 - Range of stakeholder meetings have taken place jointly with SCC
C0543 - Public consultation
Legal advice to be considered in future
Seeking external advice on process
A0194 - Independent assessment of stakeholder responses to wider short break review including Beeches (Due June 2014) (Sarah Parker, 31/07/2014, )
A0195 - Collaborative forum update due July 2014 (Sarah Parker, 29/08/2014, ) Sarah Parker DQG - Director of Quality and Safeguarding 05 - Quality To enhance quality and safety R0147 - Increasing prevelance of pressure damage across whole health economy
It has been noted across Surrey and Sussex CCGs that the prevalance of avoidable pressure damage has increased. Particularly for grade 2, 3 and 4. The increase has been noted in all sectors of the health and social care economy. There are different risks dependent on your position within the economy. For the CCG, the risk is reputational. 3-Moder ate 4-Likely 12 3-Moder ate 3-Possibl e 9 2-Minor 2-Unlikel y 4 C0432 - Pressure Damage Campaign Co-ordinated by Surrey and Sussex Area Team
C0433 - Performance management through Clinical Quality Review Meetings
C0477 - Presssure Damage Conference
Whole health economy risk and effectivelness of integrated working
Regular surveillance and discussion at Area Team through the Pressure Campaign
Regular surveillance and discussion at Clinical Quality Review Meetings with Providers
Regular surveillance by Care Quality Commission
A0202 - Pressure damage workshop (Victoria Stobbart, 31/12/2014, ) 31/03/2015 Helen Collins DQG - Director of Quality and Safeguarding 05 - Quality To enhance quality and safety R0163 - Quality Issues with the Early Pregnancy Unit at acute provider
4/6/2014: As a result of a serious untoward incident, the quality and safety of the early pregnancy unit, particularly out of hours, is questionable. Despite a robust action plan being developed by the Trust as a result of the incident, the Commissioners need to review the service to ensure it is robust and good quality for the future.
4-Major 3-Possibl e 12 3-Moder ate 3-Possibl e 9 1-Negligi ble
1-Rare 1 C0506 - Action Plan Following Serious Untoward Incident C0507 - Review of Incident and Serious Incident Reporting
Low levels of incident reporting at trust
Report on progress of renew of EPU
A0188 - Re-shaping the Early Pregancy Unit Service through Commissioning (Sarah Casemore, 28/11/2014, ) A0229 - SI Action plan (Helen Collins, 01/04/2015, ) 01/04/2015 Helen Collins DOCC - Director of Clinical Commissioning 04 - Programme Delivery To reduce inequalities in health R0035 - Inequality of uptake widens gaps - public health
Encouragement to increase physical activity/reduce alcohol consumption/give up smoking is adopted by those in less deprived areas increasing the gap in inequality (programme delivery) 3-Moder ate 3-Possibl e 9 3-Moder ate 3-Possibl e 9 0 C0064 - Monitoring uptake of initiatives. C0065 - Coordinated action by Healthy Guildford Group C0066 - Waverley Communities Health and Social Inclusion group C0070 - Health and well-being board
Health and well-being board not established
Monitoring of interventions reported to the local health and well-being board.
A0020 - Links to public health analysis team (Vicky Evans, 23/08/2013, ) 05/07/2013 Joanna Barker DQG - Director of Quality and Safeguarding 04 - Programme Delivery Organisational excellence R0125 - Effective primary care liaison (IG and clincial incidents)
We might not be sighted on quality issues in primary care, Given the challenges faced by the Area Team of NHS England.
If we are unable to support to member practices on live IG issues or serious clincial incidents then these problems may interfere with our ability to provide GP IT service and other support and may also adversely affect our relations with member practices.
3-Moder ate 3-Possibl e 9 3-Moder ate 3-Possibl e
9 0 C0351 - Informal support from CCG staff
C0367 - Priamary Care Safety Champions
C0508 - Primary Care training plan (AT)
C0552 - Quality Surveillance Group - internall (local) and regionally (external)
No confirmed guidance from LAT.
CQC monitoring NHS England
A0059 - Primary Care training plan (AT) (Samantha Chalmers, 01/08/2014, )
A0060 - Informal practice visit (Samantha Chalmers, 29/08/2014, )
A0191 - Investigate possibility of SI reporting to be managed via GP confederation (Samantha Chalmers, 01/09/2014, )
Responsible
Directorate Nature of Risk Objectives Risk Risk Detail
Rating Impact Rating Likeli Inherent Score Curren Impact Curren Likeli Curren Score Target Impact Target Likeli Target
Score Controls Gaps in control or action required Assurances Future actions
Completion Date Handler DGC - Director of Governance and Compliance 01 - Compliance Organisational excellence R0121 - Emergency Preparedness and Resilience Response arrangements - Compliance with the requirements of the Civil Contingencies Act
If the EPRR arrangements are not in place then the organisation will not meet its statutory requirements under the CCA as a Cat2 responder. Knowledge of the Cat2 requirements of a CCG is limited and does not reflect the former arrangements used by the PCT. An incomplete understanding of the EPRR requirements may lead to incomplete or inappropriate plans to be put in place by the CCG, or incomplete or inappropriate expectations made by the provider organisations during a Major Incident.
4-Major 5-Almost Certain 20 4-Major 2-Unlikel y 8 4-Major 2-Unlikel y 8 C0336 - Attendance at the LHRP forum and operational group meeting C0337 - On-call rota and protocol C0338 - Emergency Prepareness and Resilliance Response Plan and Policy
C0339 - Cascade systems for EPRR alerts to care homes and GPs C0379 - Completion of surge and escalation plan by urgent care board C0380 - Self assessment assurance against the EPRR framework C0399 - NHS England Assurance Framework
Awaiting further guidance for some aspects from LAT.
External monitoring by LAT for compliance via evidence based assessments.
A0156 - Individualised learning for on-call managers re organisational capabilities (Samantha Chalmers, 31/08/2014, )
A0157 - Exercise testing Feb 15 (Samantha Chalmers, 30/04/2015, )
A0158 - Link in with acute provider 'page one' system for on-call managers (Samantha Chalmers, 31/08/2014, ) A0190 - Draft pandemic flu plan (Samantha Chalmers, 29/08/2014, ) 30/04/2015 Samantha Chalmers DGC - Director of Governance and Compliance 07 - Transition Organisational excellence R0109 - Governance and policy control, including FOI's and Complaints falls short of expected standards
If we do not put in place a suitable system and process to reveiw and adopt clinical and corporate governance policies and procedures then the CCG falls short of expected legistlative standards of governance. (Compliance, reputation) 4-Major 4-Likely 16 4-Major 2-Unlikel y 8 2-Minor 2-Unlikel y 4 C0208 - Organisational Development Plan refresh 2013-14 C0261 - CCG Constitution. C0266 - PPG and Patient Engagement Strategy. C0277 - Policy for policies
Capacity within teams may hinder progress.
No rolling forward plan for review/audit
All Directors own policy implementation Internal Audit LAT Q4 assurance letter
A0055 - H&S support from CSU for essential policies (Samantha Chalmers, , )
A0056 - Compliance audit (Daniel Lo Russo, 31/10/2014, ) A0089 - CCG is an active member of the H&WBB (Elaine Newton, , ) 01/04/2015 Daniel Lo Russo DQG - Director of Quality and Safeguarding 05 - Quality To enhance quality and safety R0129 - Quality of Service Provided by Acute Trust Not Meeting Commissioner Expectations
Patients who receive treatment at an acute trust may experience sub-optimal quality of service on safety, clinical effectiveness and general experience. This could result in extended length of stay, readmission, increased risk of mortality, psychological trauma, additional treatments originally not required. It may also result in G&WCCG being perceived at not meeting their commissioning intentions, possibly bringing the organisation into disripute.
5-Catastr ophic 5-Almost Certain 25 3-Moder ate 2-Unlikel y 6 2-Minor
1-Rare 2 C0291 - Head of Quality Assurance in post
C0359 - Performance management C0360 - Sharing of quality intelligence with other key stakeholders
C0361 - Sourcing other healthcare providers for various services C0362 - Notification of concerns to relevant regulators (HSE-CQC)
Informal meetings required to develop working relationship. Weekly on-site inspections to be instigated.
Weekly reports around perfomance against infection control targets.
Concerns are being adressed via formal resolution process and contract management. Monthly reports to identify improvements. 30/09/2014 Helen Collins DQG - Director of Quality and Safeguarding 05 - Quality To enhance quality and safety R0150 - Quality and timliness of Serious Incident investigations, reporting and closure
A larger proportion of serious incidents that occured at a Commissioned service - acute provider have not been submitted for closure within the NHS England specified timescales. The delay poses a patient safety and reputational risk. In addition, there are associated risks with the newly established SI sub-committee in particular, they are as follows: 4-Major 3-Possibl e 12 3-Moder ate 2-Unlikel y 6 1-Negligi ble
1-Rare 1 C0437 - Serious Incident Closure Plan
C0438 - Clinical Quality Review Meetings
C0478 - Deputies to attend meetings to prevent delays due to non quorate meetings.
Learning events accross surrey to be established.
Monthly serious incident sub-committee
Monthly serious incident paper
Quality controll process prior to submission for closure NHSE final approval of C2 incidents
A0133 - Production of Serious Incident Closure Plan (Helen Collins, 30/04/2014, )
A0134 - Liaison with Area Team for Grade 2 Closures (, 30/06/2014, )
A0163 - Learning events (Helen
30/09/2015 Helen Collins DGC - Director of Governance and Compliance 04 - Programme Delivery To reduce inequalities in health R0162 - Friends and Family Test
If the Friends and Family Test is discontinued post-pilot there could be reputational damage to the CCG regarding appropriate expenditure of resources. If the Friends and Family Test is continued and fails to deliver meaningful data, there could be also be reputational damage to the CCG. 2-Minor 4-Likely 8 2-Minor 3-Possibl e 6 2-Minor 2-Unlikel y
4 C0554 - Weekly Software version release updates
Selection of provider did not follow reccomended procedures
NHSE oversight
Observatory analytical team oversight
A0231 - QES FFT system presentations (Liz Patroe, 30/09/2014, )
30/09/2014 Liz Patroe
Responsible
Directorate Nature of Risk Objectives Risk Risk Detail
Rating Impact Rating Likeli Inherent Score Curren Impact Curren Likeli Curren Score Target Impact Target Likeli Target
Score Controls Gaps in control or action required Assurances Future actions
Completion Date Handler DOCC - Director of Clinical Commissioning 05 - Quality To reduce inequalities in health R0152 - The delivery of PHBs that demonstrates the parity of services available across regions
If we can't demonstrate that we have taken into consideration the range of services covered by other geographic regions and manage patient/carer expectations, then there may be financial conseques (appeals), reputational risk of poor publicity and failure of our statutory duty for equality, accessability and meeting the health needs of the population.
3-Moder ate 4-Likely 12 1-Negligi ble 3-Possibl e 3 1-Negligi ble 4-Likely 4 C0434 - Collaborative arrangements with other CCGs C0517 - Stakeholder engagement events C0518 - Regular reports to CCG collaboratives and Childrens Health and Wellbeing Board
C0545 - SEN new legislation work
No assurance for specialist services and universal HCB
Surveilance by Surrey county council using appeals process for Educaltion Healthcare Plans
A0129 - Working group with Surrey County Council, Educaltion, Family Voice re publicising the changes (Diane Mccormack, 30/09/2014, ) A0221 - Publish information on children's section of website (Diane Mccormack, 30/09/2014, ) A0226 - Meeting with NHS
30/09/2014 Diane Mccormack
