North Essex Partnership NHS Foundation Trust
Risk and Governance Executive Report
(April - June 2011)
The group has met three times during this period, however the June meeting was not
a formal meeting but a discussion around the function and effectiveness of the
The June meeting had the following aims and objectives:
Improve the functioning of the RGE
Manageable agenda – utilisation of sub groups
Make good use of processes prior to papers coming to RGE and Discipline
around actions before papers reach RGE
Have a clearer distinction in the role that RGE is performing - potential tension
between RGE role and Clinical Boards
Understanding the key risks around patient care as the role of the RGE
Some of the practical outcomes were:
a restructuring of the agenda,
timing and priorisation of items,
ensure the risk register and assurance framework has sufficient focus.
The formal agenda is divided into five parts:
Quality and Audit
Action plans/ Monitoring
Business and reports
2) Assurance and Feedback
The group has reviewed the risk register and assurance framework and these will be
submitted to the Board separately. The risk register is currently being rescored in
light of changes to the risk descriptions to bring them up to date. The register itself
has been enhanced to include priorisation of actions, reporting / monitoring
arrangements on progress.
There has also been a significant move forward with the monitoring of mandatory
training through the OLM system including the integration of E-learning requirements
in the Trust.
CQC responsive review reports were received in March for four units and the group
is monitoring both the action plan in response to these visits as well as the provider
compliance evidence for all locations in the Trust.
Page 1 of 3
3.1) Privacy and Dignity
The group has received the audit report on privacy and dignity standards and a Trust
action plan has been produced and published in line with national requirements.
There are no significant gaps in compliance and the Trust continues to meet the
mixed sex accommodation standards.
3.2) Serious Incidents
The group received annual reports during this quarter on serious incidents to gain
assurance that the process of investigations is robust and the lessons and
recommendations are being actioned. The group has received a Trust action plan to
ensure that themes and patterns are being addressed when they occur in the serious
incident process. The group also reviews in detail high risk serious incidents to
ensure that the recommendations have been addressed. This report has already
been submitted to the Board as a separate item.
3.3) Security Management
The group has agreed the workplan for the coming year for Security management.
3.4) Mental Capacity Act and Deprivation of Liberty
The Mental Capacity Act and Deprivation of Liberty Annual report has been received.
The Trust continues to perform well in this area. New Guidance on Deprivation of
Liberty has been piloted and is now being incorporated into the Trust’s guidance in
3.5) Dignity and Respect at Work
The Dignity and Respect at Work report was received and the group noted an
increase in the number of cases and this corresponded with the staff survey results.
This was being addressed through Health and Wellbeing group.
The group continues to monitor registrations and induction of staff. Local induction
continues to be a low level of compliance with Trust standards and this is being
closely monitored and relevant managers notified.
The group analyses incidents that occur throughout the Trust through the use of the
patient safety dashboard and at the May 2011 meeting there was a review of the
overall year’s performance The highlights included:
A significant reduction in patient falls
Violent incidents down and particularly physical assaults to staff
Increase in staff reported incidents under RIDDOR regulations to the HSE
Good level of compliance with three mandatory training courses – Fire, manual
handling and Ethical care, control and restraint.
The group continues to receive ‘hot spots’ matrix of all inpatient wards against 13
metrics.- these cover all three domains, patient safety, clinical effectiveness and
5) Central Alert System including Medicines
Page 2 of 3
The group receives alert updates monthly and the only outstanding alerts relate to
medicines safer insulin administration. The alert on Lithium was signed off during the
first quarter. The Trust is now compliant with the safer insulin alert.
6) Information Governance
The group has received an update on compliance with new toolkit requirements and
this continues to be monitored in detail by the information governance and security
7) NHSLA assessment
The group has received feedback on the successful Level 1 assessment.
8) Quality and Audit
The three year audit plan has been signed off and the group is awaiting the
development of a new prioritised audit plan. Any audits which receive limited
assurance continued to be monitored.
The group continues to monitor the development of a quality dashboard and has
signed off the control plan for the development of metrics. The group is progressing
with the integration of reports and information to the high level groups in the Trust in
order to streamline the process and have a robust mechanism for safeguarding data
The group has commissioned the development of a long term quality strategy and
have approved the interim quality strategy for six months.
The group is reviewing the Quality and Risk profile via an exception report; the profile
changes monthly and the group is developing an understanding of the influences and
external reporting that impact on this dashboard.
9) Policy Approval
The following corporate policies have been approved:
Older adult CMHT operational policy
Learning and Development Policy
Management of illicit Substances policy
Care of the Bariatric Service user Policy
Manual Handling Policy and procedure
Infrared Alarm System Policy
Transitional protocol CAMHS to AMHS
Emergency Admissions Procedure
Patients’ Belongings Policy
Page 3 of 3