10.1 The Chief Executive
The Chief Executive is the Accountable Officer and has overall responsibility for Risk Management. The Chief Executive has delegated this responsibility to an Executive Lead for Risk (Director of Nursing). The Executive Lead for Risk is responsible for reporting to the Trust Board on the development and progress of Risk Management, and for ensuring that the Risk Management Strategy is implemented and evaluated effectively.
10.2 Executive and Non-Executive Directors
The Executive and Non Executive Directors have a collective responsibility as a Trust Board to ensure that the Risk Management processes are providing them with adequate and appropriate information and assurances relating to risks against the Trust’s objectives.
The Executive and Non Executive Directors are responsible for ensuring that they are adequately equipped with the knowledge and skills to fulfil this role. Risk Management training sessions can be accessed via the Risk Department but as a minimum the Risk Manager and Executive Lead for Risk will co-ordinate an annual workshop and update for Trust Board members.
The Executive Directors are accountable and responsible for ensuring that the Corporate Directorates are implementing the Risk Management Strategy and related policies. They also have specific responsibility for managing the Trust’s principal risks, which relate to their Directorates. For example:
The Director of Finance for managing the Trust’s principal risks relating to ensuring financial balance,
Director of Nursing for managing the principal risks relating to clinical quality, nursing workforce and infection control as DIPC.
Director of Organisational Development and People is responsible for managing the Trust’s principal risks relating to Health and Safety and Workforce planning.
The Medical Director is responsible for managing risks associated with Medical Workforce planning and clinical effectiveness.
Chief Operating Officer for operational performance related risks.
These designated Directors sit on the appropriate Assurance Committees which cover their area of risk.
The Non-Executive Directors have a responsibility to scrutinise and, where necessary, challenge the robustness of systems and processes in place for the management of risk.
10.3 Head of Risk Management
The Head of Risk Management is responsible for:
Maintaining and updating appropriate Risk Management Policies and procedures;
Working with the Board Secretary to ensure there is a clear and dynamic link between the Board Assurance Framework and Corporate Risk Register;
Ensuring the Trust has a comprehensive and dynamic Risk Register and working with Directorate Management Teams to ensure that they understand their accountability and responsibilities for managing risks in their areas;
Ensuring that Directorates know how to access their incident data;
Ensuring information is provided on incident data to the Clinical Governance Committee, and Trust Board;
Presenting risk reports at the CCG Clinical Quality Review Meeting (CQRM) in line with contract requirements;
Producing and coordinating Risk Management training programmes in conjunction with the Patient Safety Facilitator and other departments such as Customer Care.
Collaborating with external stakeholders’ key to Risk Management e.g. Commissioners, CQC, NHSI and other Trusts.
Ensuring that there is an appropriate and named point of contact for patients and families during the Serious Incident review process.
10.4 Board Secretary
The Board secretary is responsible for:
10.5 Specialist Areas
The Head of Facilities has delegated responsibility for ensuring that safe systems of work are in place for the management of catering, transport, decontamination, security, and waste management risks.
10.6 Directorate Management Committees
Directorate Management Committees (DMC) are accountable and have authority to ensure appropriate risk management processes are implemented within their respective directorates and areas of authority. Each member of the DMC should be aware of their clear lines of accountability for risk. Each Directorate Management Committee is required to:
- Work proactively to achieve the Trusts Key Performance Indicators for Risk Management.
- Understand and implement the Risk Management Strategy and related policies.
- Ensure that appropriate and effective risk management processes are in place within their delegated areas.
- Ensure Directorate activity is compliant with national risk management standards and safe practices, alerts etc.
- Develop specific objectives within their service plans which reflect their own risk profile and the management of risk.
- Risk assesses all business plans/service developments including changes to service delivery.
- Ensure that risk assessments, both clinical and non-clinical, are undertaken throughout their areas of responsibility. The risks identified will be prioritised and action plans formulated. These action plans will be monitored through the performance meetings.
- Maintain a directorate risk register (clinical, non-clinical and financial). Formally reporting high and extreme risks via the performance meetings.
- Report all incidents, including near misses, in accordance with the Adverse Events Reporting Policy and identify action taken to reduce or eliminate further incidents.
- Undertake investigation into all serious incidents, in accordance with the Adverse Event Reporting policy providing evidence of local resolution and learning.
- Disseminate learning and recommendations made as a result of incident investigations, clinical reviews, and serious incident inquiries within their areas of responsibility, ensuring recommendation outcomes are fed back to the Head of Risk Management.
- Monitor and report on the implementation and progress of any recommendations made which fall within their area of responsibility i.e. within the Directorate
- Ensure that all staff are made aware of risks within their working environment and their personal responsibilities within the risk management framework.
- Identify own training needs to fulfil the function of managing risk as a senior manager. As a minimum ‘Risk’ updates will be provided via the Directorate performance meetings. Further training can be accessed via the Risk Department
10.6 Departmental Managers/ Clinical Leads
Departmental Managers/Clinical Leads are accountable and have authority for the following:
- Ensuring that appropriate and effective risk management processes are in place within their designated area(s) and scope of responsibility as per this Strategy and related Risk Management Policies.
- Adverse Events are reported, reviewed and investigated thoroughly and in a timely way.
- Staff receive feedback about incidents reported, remedial actions put in place, are encouraged to engage in the resolution of problems and sharing learning wider.
- Ensuring that the grading of incidents are appropriate and regulated actions taken where Duty of Candour is triggered
- Disseminating learning and implementing recommendations made as a result of incident investigations, clinical reviews, and serious incident inquiries within their area of responsibility.
- Monitor and report on the implementation and progress of any recommendations made which fall directly within their area of responsibility i.e. within the Department.
- Maintaining a dynamic departmental risk register
- Ensuring that where high or extreme risks are identified these are brought to the attention of the Directorate Management Team for inclusion onto the Directorate Risk Register.
- Ensuring that all staff are made aware of these risks within their work environment and are aware of their individual responsibilities for raising concerns.
- Ensuring that all staff have appropriate information, instruction, and training to enable them to work safely.
- Ensuring that all new staff attend Trust Induction, receive a departmental induction and are released for mandatory training.
10.7 All Staff
All Staff are required to:
Be conversant with the Risk Management Strategy and have a working knowledge of all related risk polices.
Comply with Trust policies, procedures and guidelines to protect the health, safety, and welfare of any individuals affected by Trust activity
Acknowledge that risk management is integral to their working practice within the Trust.
Report all incidents and near misses in accordance with the Adverse Events Reporting Policy and take action to reduce or eliminate further incidents.
Report any risk issues to their line manager
Participate in the investigation of any adverse events as requested.
Attend mandatory training appropriate to role.