Public Board of Directors papers 27.01.22

13.1 Corporate risk register The corporate risk register is derived from those risks agreed by the Directors / Deputy Chief Operating Officers to potentially have Trust wide impact or an impact on the delivery of strategic objectives. A twice yearly extract of the corporate risk register is presented to the risk & quality governance committee. 13.2 Divisional and Departmental risk registers Each division is required to have a divisional risk register based on extreme and high level corporate risks and local risk assessment scores. Ward and departmental managers are responsible for managing risks locally using risk registers for each clinical and non-clinical area and for reviewing and updating these registers. Departmental managers must address risk issues as they arise wherever possible and put into place treatment plans as risks are identified. 13.3 Review of the organisation-wide risk register Risks scoring 15+ on the risk register are formally reviewed at each meeting of the risk and quality governance committee when a representative from the division will be required to attend to present their intended risk treatment action plan as requested. A report of a review of the full register (i.e. all risks recorded on Datix) for each division is submitted at least once a year to the risk and quality governance committee in the form of a presentation to highlight current risks and changes made since the previous report. This ensures that the Board of Directors and senior management are aware of the significant risks for the Trust. Risks that are overdue for review will be reported through the performance management process. 13.4 Escalation of Risk All extreme ≥15 level risks must be reviewed monthly by the Director / Deputy Chief Operating Officer in each division and reported to the divisional boards and risk and quality governance committee. All risks graded 10+ on the risk register must be reviewed quarterly by each division and documented clearly in the divisional board meeting minutes. All risks graded 1-9 on the risk register must be reviewed quarterly by each team or department and any issues escalated to divisional level as appropriate. Risks which materially change the content of the corporate risk register may be brought to the attention of the Board of Directors at any time, initially via the private section of the Board. The Board will prescribe or approve a suggested course of action in such circumstances. Any serious risks to corporate and divisional objectives must be brought to the immediate attention of the appropriate management. Risks which apply, or have the capacity to apply, to all or the greater part of the Trust and which normally have to be managed or resolved at corporate level must be brought to the attention of the risk and quality governance committee for inclusion on the corporate risk register.

14.0 AGGREGATING DATA AND LEARNING FROM INCIDENTS, COMPLAINTS AND CLAIMS

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

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