Public Board of Directors papers 27.01.22

the Trust in a range of scenarios that would limit the operating capacity of the organisation. These plans are tested in line with the requirements of the Civil Contingencies Act, and learning from these tests is communicated back into relevant groups to ensure the processes are refined. • Implementation of clinical guidance – The Trust has mechanisms in place to implement the latest guidance and recommendations – these processes are covered by the Management of National Clinical Guidelines policy. • Standards and Accreditation – The Trust ensures that it meets (and aims to exceed) a range of standards and accreditations. Many of these are covered by the Management of external agency visits, inspections and accreditations policy. • Audit Activity (clinical, internal and external) – There is extensive audit activity within the Trust covering a range of issues. Findings from these reviews are fed back to appropriate members of staff, and reports made to the clinical and research effectiveness committee and the Board of Director’s assurance committees. • Reports to Risk and Quality Governance Committee and/or Management Board on key Trust priorities – Monthly reports are made identifying potential risks to the Trust’s strategic priorities, and what actions are being taken to minimise these risks. • ‘ True for us’ Learning - The Trust seeks to learn from the experiences of other organisations. For example, published reports from key regulators are always reviewed, with findings compared to existing Trust practice. • Training – Extensive training activity takes place in the Trust on a range of subjects. Much of this is regulated by professional bodies such as the GMC, NMC etc, while some is linked to individual personal development plans, or to the implementation of Trust policies. As a minimum all staff receive appropriate essential training as described in the Corporate Essential Training Prospectus • Risk Registers - The Trust has a robust process for the management of the Trust-wide risk register. The Trust-wide risk register is underpinned by comprehensive risk assessment systems in all areas, and is collated within the electronic Datixweb risk management system. 11.2 Reactive risk processes Learning and potential risks are identified from adverse events or complaints and concerns reported by patients and / or their carers to the Trust. A weekly process for the early triage of incidents, complaints and claims is undertaken by an Executive Review Group (ERG). This group receives the outcomes of root cause analyses of investigations commissioned by the ERG Panel. Incidents - The Trust has a system for reporting adverse incidents, including serious incidents, set out in the Incident Reporting and Investigation Policy. All notified incidents are graded using a simple risk assessment matrix, consistent with that used for risk assessment. Complaints - The Trust has a well-established complaints process, set out within the Complaints and concerns Policy which ensures that all concerns are responded to within the approved timescales. All serious complaints are the subject of a full root cause analysis. Information and action plans arising from complaints are used to develop or change the service delivery. Claims & litigation - The Quality and Standards team works closely with the divisions to enable the early identification of potential legal claims against the Trust as set out in the Claims Policy. Inquests - The Quality and Standards team work with Trust clinicians and HM Coroner to ensure the best outcomes for families and the Trust from the inquest process, as set out in the Inquest Policy. Any concerns or recommendations raised by the Coroner are communicated appropriately to ensure that remedial action is taken. Debriefing/Post Event Analysis - Potential risks and learning are identified following all reactive risk management activities as an integral part of these processes. Appropriate management action put in place to reduce or eliminate the possibility of a similar occurrence.

Risk management strategy and Policy 2021-2024 Document ref: RM01 Version 04

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