Strategic Objective 1 – Inspirational People
Risk Description 1.1 Failure to recruit and retain safe levels of high calibre staff and support positive values, culture and speaking up. Risk Appetite – the Trust has very low/averse appetite for risks that impact on safe staffing, calibre of leadership, poor culture, and impact on ability of staff to speak up	Date last reviewed: September 2023	Director Lead: Cath Byford, Chief People Officer and Deputy CEO	Board Committee: People and Remuneration Committee
Consequence of risk: If the trust fails to recruit and retain staff with the right values, skills and competencies and support the right culture then this impacts on delivering safe and effective services	Risk Rating over time New BAF	Rationale for current score: (l x c) Metrics show performance in key areas not improving High Risk 4 x 4 = 16
Target Rating: (l x c) and Date to reach target 3 x 4 = 12 December 2024
Controls (what are we currently doing about the risk?) Improvement Programme culture and leadership pillar work Safe staffing - e-rosters, safe staffing tool, nursing establishment review, agency cover for vacancies (with agency approval process); job planning Recruitment & retention controls: Fair Recruitment panels; TRAC & Recruitment Pipeline Management & Recruitment Standards; values based recruitment; exit interviews and early conversations; Recruitment and retention group; medical recruitment strategy. New corporate and clinical induction; follow up of new staff. Absence management programme Leadership controls: Leadership competency Framework; Leadership development programme; talent management programme, Board succession planning process; Board and senior leaders development; Independent Freedom to Speak Up Guardian service Big Conversation, quarterly pulse surveys, Staff survey, medical engagement survey Care Group local governance committees and QPMs – scrutiny of key workforce metrics System wide integrated workforce plan is aligned with corporate strategy	Assurances (how do we know if the things we are doing are having impact?) Integrated Quality Performance Report (IQPR) workforce metrics, reported to People & Remuneration Committee and Board show: annualised sickness absence levels outside of target but reducing, supervision and appraisal remain below target; mandatory training improved with most care groups close to target; number of staff in post continues to increase, but medical vacancies remain an issue although 7 substantive consultants recruited in this period. Turnover of staff is reducing however, leavers with less than 2 years of service is still very high, particularly admin and support workers. Guardian of Safe working report to board FTSU reports to board outlines numbers/themes raised and actions taken and need for more resource to support Guardian Developing culture dashboard and metrics to measure leadership development programmes – new indicators proposed alongside current indicators in staff survey and pulse surveys Internal audit review of Grievance Reporting and Freedom to Speak Up gave reasonable assurance. People & Remuneration Committee tracking all audit recommendations
Gaps (in controls and assurances) Address issues raised by CQC, Staff Survey and ‘A Big Conversation’ High use of agency staffing, vacancy hot spots, particularly medical recruitment, sickness absence Sustainability of improvements with supervision and appraisal	Mitigating actions (what have we done/what more should we do?) Culture & leadership pillar leading programme of improvement addressing feedback from staff survey, Big Conversation and FTSU and issues of discrimination and bullying and communicating broad actions taken as a result of speaking up to build trust and safety; Engaging staff in refresh of the Trust values. Implementing the national NHSE Civility and Respect framework

Strategic Objective 1 – Inspirational People

Risk Description 1.1 Failure to recruit and retain safe levels of high calibre staff and support positive values, culture and speaking up. Risk Appetite – the Trust has very low/averse appetite for risks that impact on safe staffing,

calibre of leadership, poor culture, and impact on ability of staff to speak up

Date last reviewed:

September 2023

Director Lead: Cath Byford, Chief People Officer and Deputy CEO

Board Committee:

People and Remuneration Committee

Consequence of risk:

If the trust fails to recruit and retain staff with the right values, skills and competencies and support the right culture then this impacts on delivering safe and effective services

Risk Rating over time

New BAF

Rationale for current score: (l x c)

Metrics show performance in key areas not improving

High Risk 4 x 4 =

Target Rating: (l x c) and Date to reach target

3 x 4 = 12 December 2024

Controls (what are we currently doing about the risk?)

Improvement Programme culture and leadership pillar work
Safe staffing - e-rosters, safe staffing tool, nursing establishment review, agency cover for vacancies (with agency approval process); job planning
Recruitment & retention controls: Fair Recruitment panels; TRAC & Recruitment Pipeline Management & Recruitment Standards; values based recruitment; exit interviews and early conversations; Recruitment and retention group; medical recruitment strategy. New corporate and clinical induction; follow up of new staff. Absence management programme
Leadership controls: Leadership competency Framework; Leadership development programme; talent management programme, Board succession planning process; Board and senior leaders development;
Independent Freedom to Speak Up Guardian service
Big Conversation, quarterly pulse surveys, Staff survey, medical engagement survey
Care Group local governance committees and QPMs – scrutiny of key workforce metrics
System wide integrated workforce plan is aligned with corporate strategy

Assurances (how do we know if the things we are doing are having impact?)

Integrated Quality Performance Report (IQPR) workforce metrics, reported to People & Remuneration Committee and Board show: annualised sickness absence levels outside of target but reducing, supervision and appraisal remain below target; mandatory training improved with most care groups close to target; number of staff in post continues to increase, but medical vacancies remain an issue although 7 substantive consultants recruited in this period. Turnover of staff is reducing however, leavers with less than 2 years of service is still very high, particularly admin and support workers.
Guardian of Safe working report to board
FTSU reports to board outlines numbers/themes raised and actions taken and need for more resource to support Guardian
Developing culture dashboard and metrics to measure leadership development programmes – new indicators proposed alongside current indicators in staff survey and pulse surveys
Internal audit review of Grievance Reporting and Freedom to Speak Up gave reasonable assurance. People & Remuneration Committee tracking all audit recommendations

Gaps (in controls and assurances)

Address issues raised by CQC, Staff Survey and ‘A Big Conversation’
High use of agency staffing, vacancy hot spots, particularly medical recruitment, sickness absence
Sustainability of improvements with supervision and appraisal

Mitigating actions (what have we done/what more should we do?)

Culture & leadership pillar leading programme of improvement addressing feedback from staff survey, Big Conversation and FTSU and issues of discrimination and bullying and communicating broad actions taken as a result of speaking up to build trust and safety; Engaging staff in refresh of the Trust values. Implementing the

national NHSE Civility and Respect framework

Strategic Objective 2 – Exceptional care
Risk Description 2.1 Risk of failure to deliver high standards of quality, safety and effectiveness. Risk Appetite – the Trust has a very low/averse appetite for risks that impact on quality, safety and patient experience	Date last reviewed: September 2023	Director Lead: Tumi Banda, Interim Chief Nurse. Alex Lewis, CMO	Board Committee: Quality Assurance Committee (QAC)
Consequence of risk: If the Trust fails to deliver high quality, safe effective services, this impacts on service user outcomes, confidence and trust by the public, poor CQC ratings and continuation in Recovery Support Programme and poor staff morale and retention.	Risk Rating over time New BAF	Rationale for current score: (l x c) Progress, but yet to fully address the CQC concerns as per quality and safety metrics High Risk 4 x 4 = 16
Target Rating: (l x c) and Date to reach target 3 x 4 = 12 once must dos addressed March 2024
Controls (what are we currently doing about the risk?) Daily and weekly huddles focused on safety and quality matters - from clinical teams to the executive Patient Safety Framework review processes following incidents, this is now embedded within the Trust, with regular patient safety incident reporting Safe staffing controls –Roster Check & Challenge meetings are continuing every 4 weeks to monitor inpatient roster performance & to scrutinise rostering KPI’s Supervision, Appraisals, Mandatory Training. Clinical Guidance via policy and operational procedures. Application of NHSE Patient Safety Framework including incident reporting system. Availability of multiple routes for staff to raise query and concern. Triangulation of quality outcomes with feedback from experience from carers and patients (e.g., Friends and Family Test, Complaints, People Participation Team) to receive and act upon user and carer feedback. Risk Management Process. Implementation from August 2023 of structured Early Warning Trigger Tool and supporting interventions for clinical teams. Improvement Programme Quality & Safety pillar phase 2 work focused on local governance systems, medicines optimisation, safety culture, learning from deaths, physical health, CQC Must dos.	Assurances (how do we know if the things we are doing are having impact?) Integrated Quality Performance Report (IQPR) quality & safety metrics, reported to QAC and Board shows: nil never events and no prevention of future death notifications this period. Sustained reduction in self harm incidents, ligature incidents. Reduction in restrictive practice. Supervision (72%), Appraisals (81%), Mandatory Training (88%) below target. Roster data shows continued improvement for day and night fill rates, majority above target levels of 90%. Utilisation of feedback from customer services, use of the Family and Friends to inform on quality and experience of patients and carers monitored by Experience of Care Committee Triangulation with feedback from range of sources including Quality & Safety reviews which provides ongoing assessment against standards with action plans to improve Clinical Audit Programme, approved by QAC and A&RC, reporting on themes to Quality Committee Evidence Assurance Group (EAG) have signed off Must Do actions according to plan

Strategic Objective 2 – Exceptional care

Risk Description 2.1 Risk of failure to deliver high standards of quality, safety and effectiveness. Risk Appetite – the Trust has a very low/averse appetite for

risks that impact on quality, safety and patient experience

Date last reviewed:

September 2023

Director Lead:

Tumi Banda, Interim Chief Nurse. Alex Lewis, CMO

Board Committee:

Quality Assurance Committee (QAC)

Consequence of risk:

If the Trust fails to deliver high quality, safe effective services, this impacts on service user outcomes, confidence and trust by the public, poor CQC ratings and continuation in Recovery Support Programme and poor

staff morale and retention.

Risk Rating over time

New BAF

Rationale for current score: (l x c) Progress, but yet to fully address the CQC concerns as per quality and safety metrics

High Risk 4 x 4 =

Target Rating: (l x c) and Date to reach target

3 x 4 = 12 once must dos addressed March 2024

Controls (what are we currently doing about the risk?)

Daily and weekly huddles focused on safety and quality matters - from clinical teams to the executive
Patient Safety Framework review processes following incidents, this is now embedded within the Trust, with regular patient safety incident reporting
Safe staffing controls –Roster Check & Challenge meetings are continuing every 4 weeks to monitor inpatient roster performance & to scrutinise rostering KPI’s
Supervision, Appraisals, Mandatory Training.
Clinical Guidance via policy and operational procedures.
Application of NHSE Patient Safety Framework including incident reporting system.
Availability of multiple routes for staff to raise query and concern.
Triangulation of quality outcomes with feedback from experience from carers and patients (e.g., Friends and Family Test, Complaints, People Participation Team) to receive and act upon user and carer feedback.
Risk Management Process.
Implementation from August 2023 of structured Early Warning Trigger Tool and supporting interventions for clinical teams.
Improvement Programme Quality & Safety pillar phase 2 work focused on local governance systems, medicines optimisation, safety culture, learning from deaths, physical health, CQC Must dos.

Assurances (how do we know if the things we are doing are having impact?)

Integrated Quality Performance Report (IQPR) quality & safety metrics, reported to QAC and Board shows: nil never events and no prevention of future death notifications this period. Sustained reduction in self harm incidents, ligature incidents. Reduction in restrictive practice. Supervision (72%), Appraisals (81%), Mandatory Training (88%) below target.
Roster data shows continued improvement for day and night fill rates, majority above target levels of 90%.
Utilisation of feedback from customer services, use of the Family and Friends to inform on quality and experience of patients and carers monitored by Experience of Care Committee
Triangulation with feedback from range of sources including Quality & Safety reviews which provides ongoing assessment against standards with action plans to improve
Clinical Audit Programme, approved by QAC and A&RC, reporting on themes to Quality Committee
Evidence Assurance Group (EAG) have signed off Must Do actions according to plan

Gaps

Incomplete range of quality metrics on IQPR and IQPR metrics not meeting trust target (Supervision, Appraisals, Mandatory Training)
Inconsistent application of leadership and competency frameworks in inpatient services
Grant Thornton UK LLP’s audit of the processes the Trust uses to collect and report mortality data identified insufficient clarity, consistency and learning
Capacity to deliver improvement programmes at planned rate e.g., CQC Must Do actions.
Clinical Audit programme does not yet cover majority of clinical policy guidance.
Inconsistent evidence of capture and use of user and carer feedback to enable learning and service development.
Underlying cultural issues, safer staffing, retention of staff and impact on ability to sustainably deliver safety and quality.
Progression of next phase of IQPR and quality dashboard
Variation in engagement with people participation and carer engagement
There is a need to improve Local and Trust Governance structures
Issues with community services

Mitigating actions (what have we done/what more should we do?)

Agreed additional quality metrics to support IQPR metrics, but currently lack of capacity in BI team; being escalated.
Improvement focus on leadership and competency framework led by Lead Nurses. Initial plans to complete September 2023
Immediate actions undertaken in response to Grant Thornton audit report with further formulation and implementation of co-produced response plan, system formulation meeting will be held in September 2023.
Increasing capacity for delivery of local governance programme as per CQC must do. EAG continues to ensure CQC Must Do actions have sustainability, to March 2024
Implementation of Early Warning Trigger tool into community settings. Currently in Inpatient settings with rollout to Community and Crisis Teams from September 2023.
Implement agreed annual clinical audit plan (agreed at Quality Assurance Committee July 2023) with structured approach to monitoring and response to outcomes via local and Trust governance structures.
Implement Quality Account 2023/2024 Priority-Model of Care work - phase 1 in end May, initial implementation by end October 2023.
Implement Quality Account 2023/2024 Priority- Safety Culture. set up Clinical Safety Group September 2023 to oversee safety/risk workstreams including formulation, DIALOG+, safety planning, Stepping Back Safely (carers). Phase completion March 24.
Implement Quality Account 2023/2024 Priority- Using patient experience to inform service design and delivery (increasing use of FFT, % responses rating very good/ good, evidence of feedback informing service delivery). Phase completion March 24
Inpatient improvement programme –first 12 months (to July 24) reducing variation of care provision, in line with evidence based quality and safety standards and initiatives, increasing workforce competence through clinical training and development. Year one deliverable: Purposeful admission; ‘Red to Green’; Safecare; Safewards; Early Warning Trigger Tool.

Strategic Objective 2 – Exceptional care
Risk Description 2.2 Risk of failure to acquire and record accurate data on deaths and Serious Incidents will compromise learning and delivery of safe services. Risk Appetite – the Trust has a very low/averse appetite for risks that impact on quality, safety and patient experience	Date last reviewed: September 2023	Director Lead: Alex Lewis, CMO	Board Committee: Quality Assurance Committee
Consequence of risk: If the Trust fails to acquire and record accurate data on deaths and serious incidents then these compromises learning and prevention, delivery of safe services and working with partners to reduce inequalities in health care	Risk Rating over time New risk	Rationale for current score: (l x c) Progress with action plan following the Grant Thornton mortality report High Risk 4 x 4 = 16
Target Rating: (l x c) and Date to reach target 3 x 4 = 12 March 2024
Controls (what are we currently doing about the risk?) Grant Thornton action plan collates requirements for data quality controls Patient Safety Incident Response Framework (PSIRF) embedded for 3yrs – Standard Operating Policy outlines processes, assurance and evaluation including engagement with Clinical Experts and ICB colleagues to decide on safety activity and actions The Trust utilises Datix to report and monitor incidents including deaths that have occurred in the Trust or in the community Patient safety alerts and thematic reviews/audits based on emerging trends Quality and Safety Improvement programme pillar includes focus on psychological safety, Restorative Just Culture, Safety II and Civility Weekly incident (including all deaths) briefing to Executive and Senior Leaders Weekly patient safety, safeguarding, legal, H&S and quality teams huddle on ‘soft intelligence’ and areas for escalation to senior leadership. PSI mortality panel twice a week and mortality natural cause deaths panel will mirror this bi-weekly Daily mortality huddles (combined PSI/morality natural cause deaths) to review all notifications of deaths in any 24hour period or weekend period on a Monday	Assurances (how do we know if the things we are doing are having impact?) Grant Thornton action plan updates to Board and Quality Assurance Committee Integrated Quality Performance Report (IQPR) quality & safety metrics, reported to QAC and Board shows: nil never events and no prevention of future death notifications this period, sustained reduction in self-harm incidents, ligature incidents. Internal Learning from deaths Forum scrutinising mortality dashboard, and ICB learning from deaths forum Mortality scrutiny panel established to review processes for natural deaths Care Group governance structures use information from learning from deaths forum to embed learning and will be supported to use the mortality dashboard to have localised oversight of deaths Monthly Clinical Safety Group to oversee safety projects including; DIALOG+, Formulation, Clinical Risk policy review, Personality Disorder pathway, Suicide and DSH Strategy (with Public Health and other stakeholders)

Strategic Objective 2 – Exceptional care

Risk Description 2.2 Risk of failure to acquire and record accurate data on deaths and Serious Incidents will compromise learning and delivery of safe services. Risk Appetite – the Trust has a very low/averse appetite for risks that impact on quality, safety and patient experience

Date last reviewed:

September 2023

Director Lead:

Alex Lewis, CMO

Board Committee:

Quality Assurance Committee

Consequence of risk:

If the Trust fails to acquire and record accurate data on deaths and serious incidents then these compromises learning and prevention, delivery of safe services and working with partners to reduce inequalities in health care

Risk Rating over time

New risk

Rationale for current score: (l x c)

Progress with action plan following the Grant Thornton mortality report

High Risk 4 x 4 =

Target Rating: (l x c) and Date to reach target

3 x 4 = 12 March 2024

Controls (what are we currently doing about the risk?)

Grant Thornton action plan collates requirements for data quality controls
Patient Safety Incident Response Framework (PSIRF) embedded for 3yrs – Standard Operating Policy outlines processes, assurance and evaluation including engagement with Clinical Experts and ICB colleagues to decide on safety activity and actions
The Trust utilises Datix to report and monitor incidents including deaths that have occurred in the Trust or in the community
Patient safety alerts and thematic reviews/audits based on emerging trends
Quality and Safety Improvement programme pillar includes focus on psychological safety, Restorative Just Culture, Safety II and Civility
Weekly incident (including all deaths) briefing to Executive and Senior Leaders
Weekly patient safety, safeguarding, legal, H&S and quality teams huddle on ‘soft intelligence’ and areas for escalation to senior leadership.
PSI mortality panel twice a week and mortality natural cause deaths panel will mirror this bi-weekly
Daily mortality huddles (combined PSI/morality natural cause deaths) to review all notifications of deaths in any 24hour period or weekend period on a Monday

Assurances (how do we know if the things we are doing are having impact?)

Grant Thornton action plan updates to Board and Quality Assurance Committee
Integrated Quality Performance Report (IQPR) quality & safety metrics, reported to QAC and Board shows: nil never events and no prevention of future death notifications this period, sustained reduction in self-harm incidents, ligature incidents.
Internal Learning from deaths Forum scrutinising mortality dashboard, and ICB learning from deaths forum
Mortality scrutiny panel established to review processes for natural deaths
Care Group governance structures use information from learning from deaths forum to embed learning and will be supported to use the mortality dashboard to have localised oversight of deaths
Monthly Clinical Safety Group to oversee safety projects including; DIALOG+, Formulation, Clinical Risk policy review, Personality Disorder pathway, Suicide and DSH Strategy (with Public Health and other stakeholders)

Gaps (in controls and assurances)

Data management as systems were reliant on manual inputting with no overarching descriptive process.
Reporting – as the Grant Thornton team found there is a lack of consistency in the data presented within Board reports and the trust needed to increase clinical input into the supervision and oversight of the mortality process.
Clinical engagement – to enhance the clinical oversight of recording and classification for mortality natural cause death data and improve the data being made available for demographic analysis.
Partnership Working – the need to understand how people die from natural causes to enable learning by improving the trusts access to patients causes of death.
Governance – For the trust to agree and monitor an improvement plan which includes all actions and implement an assurance process.
Access to cause of death data via primary care/spine or other identified platform e.g. registrars office, Medical Examiners
Joined up workstream across ICS to address SMI and inequalities in health including premature death

Mitigating actions (what have we done/what more should we do?)

Urgent action is underway to address these issues recognising the importance of timely, accurate mortality (natural cause) data for the Trust's learning, and for those families, carers and loved ones of all patients who have sadly died
An Improvement Plan is in place addressing the 16 recommendations from the report.
Seagry consultancy and NSFT are reviewing technology, solutions and processes used to capture, collate and report mortality data. Interoperability, system upgrade requirement as and when required will be included as part of this review. The proposed solution is due to be tested in September 2023.
Review Mental Health Learning from Deaths are being completed by the Safety Team in line with National Quality NHSE requirements for mortality reporting.
NSFT is system discussions to collaborate on developing a system action plan to address the issues raised in Grant Thornton report, first of weekly stakeholder coproduction meetings 19 September 2023
Single point for data depository (Sharepoint); Formation of a Mortality Team; Mortality Scrutiny Panel

Strategic Objective – Exceptional care
Risk Description 2.3 – risk that growing waiting lists result in deteriorating access to timely and effective care, impacting patient safety. Risk Appetite – the Trust has a very low/averse appetite for risks that impact on quality, safety and patient experience	Date last reviewed: September 2023	Director Lead: Thandie Matambanadzo, Chief Operating Officer	Board Committee: Performance and Finance Committee
Consequence of risk: If waiting lists continue to grow, then people are unable to access timely care and treatment impacting on patient safety, outcomes and experience.	Risk Rating over time New BAF	Rationale for current score: (l x c): waiting lists waiting lists remain high since the pandemic reflecting national trends, exceeding risk appetite and representing a significant and ongoing risk to service users.
Target Rating: (l x c) and Date to reach target Target rating 3 x 3 by March 2025
High Risk	4 x 4 = 16
Controls (what are we currently doing about the risk?) Trust-wide service user tracking list (SUTL) process implemented with all care groups expected to provide monthly report to a Trust Access Group (TAG), with escalation process and reporting. Monitoring of key operational metrics reported in QPMs and via IQPR Patient flow interventions including system working on delayed transfers of care (DTOC), urgent & emergency care (UEC) programme and community transformation programmes in Norfolk and Suffolk. Advice and Guidance service. Demand & capacity work and focus on reducing people placed out of area (OOA) Access, data and delivery improvement programme pillar work.	Assurances (how do we know if the things we are doing are having impact?) TAG reviewing care group status reports on long waits, performance against agreed recovery/improvement plans and assurance around local clinical harm review processes in place. TAG escalating issues to QPMs and where necessary to performance and finance committee by the COO. The first TAG meeting was held on 31 July 2023 and the next meeting takes place on 6 October 2023. Integrated Quality Performance Report (IQPR) metrics, reported to Performance & Finance Committee and Board shows Early intervention in Psychosis treatment times continue to perform above the national target times; Eating Disorder services continue to show improved performance. Waits for assessment and treatment continue to increase with children and young people's services being amongst lowest performing areas, driven in part by an increase in the number of service users being referred onto neurodevelopmental diagnostic assessment pathways. Exponential growth in the number of service users being referred for diagnostic assessments onto neurodevelopmental pathways (including for ADHD and ASD) – across all systems in England. Given the unprecedented demand the Trust is unable to meet all the needs of service users being referred onto neurodevelopmental diagnostic pathways. Of those waiting 18 weeks or more for assessment or treatment, over 70% are related to neurodevelopmental pathways. Patient flow interventions currently being planned/deployed including system working on delayed transfers of care (DToC), urgent and emergency care (UEC) and community mental health transformation programmes across Norfolk and Suffolk.

Strategic Objective – Exceptional care

Risk Description 2.3 – risk that growing waiting lists result in deteriorating access to timely and effective care, impacting patient safety.

Risk Appetite – the Trust has a very low/averse appetite for risks that impact on quality, safety and patient experience

Date last reviewed:

September 2023

Director Lead:

Thandie Matambanadzo, Chief Operating Officer

Board Committee: Performance and Finance Committee

Consequence of risk:

If waiting lists continue to grow, then people are unable to access timely care and treatment impacting on patient safety, outcomes and experience.

Risk Rating over time

New BAF

Rationale for current score: (l x c): waiting lists waiting lists remain high since the pandemic reflecting national trends, exceeding risk appetite and representing a significant and ongoing risk to

service users.

Target Rating: (l x c) and Date to reach target

Target rating 3 x 3 by March 2025

High Risk

4 x 4 =

Controls (what are we currently doing about the risk?)

Trust-wide service user tracking list (SUTL) process implemented with all care groups expected to provide monthly report to a Trust Access Group (TAG), with escalation process and reporting.
Monitoring of key operational metrics reported in QPMs and via IQPR
Patient flow interventions including system working on delayed transfers of care (DTOC), urgent & emergency care (UEC) programme and community transformation programmes in Norfolk and Suffolk.
Advice and Guidance service.
Demand & capacity work and focus on reducing people placed out of area (OOA)
Access, data and delivery improvement programme pillar work.

Assurances (how do we know if the things we are doing are having impact?)

TAG reviewing care group status reports on long waits, performance against agreed recovery/improvement plans and assurance around local clinical harm review processes in place. TAG escalating issues to QPMs and where necessary to performance and finance committee by the COO. The first TAG meeting was held on 31 July 2023 and the next meeting takes place on 6 October 2023.
Integrated Quality Performance Report (IQPR) metrics, reported to Performance & Finance Committee and Board shows Early intervention in Psychosis treatment times continue to perform above the national target times; Eating Disorder services continue to show improved performance. Waits for assessment and treatment continue to increase with children and young people's services being amongst lowest performing areas, driven in part by an increase in the number of service users being referred onto neurodevelopmental diagnostic assessment pathways.
Exponential growth in the number of service users being referred for diagnostic assessments onto neurodevelopmental pathways (including for ADHD and ASD) – across all systems in England. Given the unprecedented demand the Trust is unable to meet all the needs of service users being referred onto neurodevelopmental diagnostic pathways. Of those waiting 18 weeks or more for assessment or treatment, over 70% are related to neurodevelopmental pathways.
Patient flow interventions currently being planned/deployed including system working on delayed transfers of care (DToC), urgent and emergency care (UEC) and community mental health transformation programmes across Norfolk and Suffolk.

Roll-out of a trust-wide demand and capacity plan, including completing community demand and capacity modelling by March 2024. Continued under-performance against plan to reduce the number of people placed out of area.
Gaps Costs, benefits and impacts of system-wide community interventions not fully understood/articulated. High demand/pressures on community teams, waits for children’s and young person’s services, demands nationally on inpatient beds. CQC reports highlighted waiting times as key issue. NHS Benchmarking shows NSFT referrals received are above national average. Impact of staffing vacancies and retention impacts on ability to deliver increased activity. Digital transformation opportunities not fully understood. Inappropriate use of out of area beds result in poorer quality outcomes for service users and undermine financial sustainability of inpatient services. Pressure on OOA being driven by a range of factors including lack of suitable accommodation in community settings, reduction of inpatient beds available in trust’s carrying high occupancy rates.	Mitigating actions (what have we done/what more should we do?) Demand and capacity roll out plan agreed to deliver community demand and capacity modelling by March 2024. Weekly waiting times meetings set up with adult community team leaders to actively seek solutions to reducing waits, strategic oversight meetings for children’s and young person’s services also meets monthly (ongoing). On-going analysis of benchmarking information to understand NSFT referrals vs national to inform future investment cases. Mental health collaboratives and system working reviewing community transformation programme, system pressures, DTOCs and use of OOA. Improvement programme pillar work continues to address Access, Data and Delivery, culture, recruitment and retention. Model of Care work will support referrers. (by Dec 2023). Improving data quality for clarity on waits and access (December 2023).

Roll-out of a trust-wide demand and capacity plan, including completing community demand and capacity modelling by March 2024.
Continued under-performance against plan to reduce the number of people placed out of area.

Gaps

Costs, benefits and impacts of system-wide community interventions not fully understood/articulated.
High demand/pressures on community teams, waits for children’s and young person’s services, demands nationally on inpatient beds.
CQC reports highlighted waiting times as key issue.
NHS Benchmarking shows NSFT referrals received are above national average.
Impact of staffing vacancies and retention impacts on ability to deliver increased activity.
Digital transformation opportunities not fully understood.
Inappropriate use of out of area beds result in poorer quality outcomes for service users and undermine financial sustainability of inpatient services. Pressure on OOA being driven by a range of factors including lack of suitable accommodation in community settings, reduction of inpatient beds available in trust’s carrying high occupancy rates.

Mitigating actions (what have we done/what more should we do?)

Demand and capacity roll out plan agreed to deliver community demand and capacity modelling by March 2024. Weekly waiting times meetings set up with adult community team leaders to actively seek solutions to reducing waits, strategic oversight meetings for children’s and young person’s services also meets monthly (ongoing).
On-going analysis of benchmarking information to understand NSFT referrals vs national to inform future investment cases.
Mental health collaboratives and system working reviewing community transformation programme, system pressures, DTOCs and use of OOA.
Improvement programme pillar work continues to address Access, Data and Delivery, culture, recruitment and retention. Model of Care work will support referrers. (by Dec 2023).
Improving data quality for clarity on waits and access (December 2023).

Strategic Objective 2 – Exceptional care
Risk Description 2.4 Risk that governance systems fail to identify and address areas of risk and concern. Risk Appetite – the Trust has a low/averse appetite for risks that impact on governance	Date last reviewed: September 2023	Director Lead: Stuart Richardson, CEO	Board Committee: Audit & Risk Committee
Consequence of risk: If governance systems fail, then this impacts on quality and safety of care, patient outcomes, CQC rating, failure to exit Recovery Support Programme (RSP)	Risk Rating over time NEW BAF	Rationale for current score: (l x c) Focus remains on improving local governance; strengthened delivery programme and additional resource Significant Risk 3 x 4 = 12
Target Rating: (l x c) and Date to reach target 2 x 4 = 4 March 2024
Controls (what are we currently doing about the risk?) Improvement programme phase 2 – focus on improving local governance as part of Quality & Safety pillar Strengthened board and committee level governance; annual review underway, ensuring floor to board reporting and assurance Continuing to improve QPMs and care group governance. NED attendance at QPMs Accountability Framework and Leadership Competency Framework (LCF) in place, but work on going to strengthen and embed Risk Management framework, policy and strategy undergoing annual review. New Board Assurance Framework linked to new Trust Strategy. Continued Corporate Risk Register scrutiny Standing Financial Instructions across N&W ICB. NHSE and system performance meetings (OAG) Evidence Assurance Group scrutinises CQC must evidence, chaired by N&W CMO) and New Recovery Support Group (RSP) established, chaired by NED, to do the same with RSP criteria evidence. Reporting to Improvement Board and Audit & Risk Committee (A&RC) respectively	Assurances (how do we know if the things we are doing are having impact?) Improvements highlighted by CQC report published February 2023, although Trust remains in RSP. Improvement Board monitoring progress with Improvement programme phase 2. Still some CQC must dos – particularly local governance and early warning indicators and more pace needed with Model of Care and MoC+ Executive and NED scrutiny and challenge of each improvement pillar work Evidence Assurance Group signing off CQC must do evidence – on track New Local Governance Delivery Group with support from NHSE. Escalating issues with recruitment for key lead post to drive programme at pace Internal Audit of BAF May 2023 ‘reasonable assurance’ opinion – actions underway to address recommendations. IQPR metrics – yes to show sustainable improvement and reflect ‘so what’ aspect of impact on service users, carers, staff Overdue risks remain on Corporate Risk Register – comply or explain approach by A&RC, along with programme of BAF risk check and challenge with exec and NED lead for each risk. Each Board committee scrutinises relevant BAF risks and high rated corporate register risks
Gaps Remaining CQC must dos and sustaining improvement Urgent improvements needed to local governance Recovery Support Programme (RSP) exit criteria and FT licence conditions Need to embed accountability framework and improve performance culture	Mitigating actions (what have we done/what more should we do?) Improvement programme phase 2 – local governance work on-going as part of Quality & Safety pillar, but with new delivery board chaired by CEO supported by workstreams, care group workshops to better engage and inject more pace, plus additional support from NHSE. Recruitment for local governance programme lead October 2023

Strategic Objective 2 – Exceptional care

Risk Description 2.4 Risk that governance systems fail to identify and address areas of risk and concern. Risk Appetite – the Trust has a low/averse appetite

for risks that impact on governance

Date last reviewed:

September 2023

Director Lead:

Stuart Richardson, CEO

Board Committee:

Audit & Risk Committee

Consequence of risk:

If governance systems fail, then this impacts on quality and safety of care, patient outcomes, CQC rating, failure to exit Recovery Support Programme (RSP)

Risk Rating over time

NEW BAF

Rationale for current score: (l x c)

Focus remains on improving local governance; strengthened delivery programme and additional resource

Significant Risk 3 x 4 =

Target Rating: (l x c) and Date to reach target

2 x 4 = 4 March 2024

Controls (what are we currently doing about the risk?)

Improvement programme phase 2 – focus on improving local governance as part of Quality & Safety pillar
Strengthened board and committee level governance; annual review underway, ensuring floor to board reporting and assurance
Continuing to improve QPMs and care group governance. NED attendance at QPMs
Accountability Framework and Leadership Competency Framework (LCF) in place, but work on going to strengthen and embed
Risk Management framework, policy and strategy undergoing annual review. New Board Assurance Framework linked to new Trust Strategy. Continued Corporate Risk Register scrutiny
Standing Financial Instructions across N&W ICB.
NHSE and system performance meetings (OAG)
Evidence Assurance Group scrutinises CQC must evidence, chaired by N&W CMO) and New Recovery Support Group (RSP) established, chaired by NED, to do the same with RSP criteria evidence. Reporting to Improvement Board and Audit & Risk Committee (A&RC) respectively

Assurances (how do we know if the things we are doing are having impact?)

Improvements highlighted by CQC report published February 2023, although Trust remains in RSP. Improvement Board monitoring progress with Improvement programme phase 2. Still some CQC must dos – particularly local governance and early warning indicators and more pace needed with Model of Care and MoC+
Executive and NED scrutiny and challenge of each improvement pillar work
Evidence Assurance Group signing off CQC must do evidence – on track
New Local Governance Delivery Group with support from NHSE. Escalating issues with recruitment for key lead post to drive programme at pace
Internal Audit of BAF May 2023 ‘reasonable assurance’ opinion – actions underway to address recommendations.
IQPR metrics – yes to show sustainable improvement and reflect ‘so what’ aspect of impact on service users, carers, staff
Overdue risks remain on Corporate Risk Register – comply or explain approach by A&RC, along with programme of BAF risk check and challenge with exec and NED lead for each risk. Each Board committee scrutinises relevant BAF risks and high rated corporate register risks

Gaps

Remaining CQC must dos and sustaining improvement
Urgent improvements needed to local governance
Recovery Support Programme (RSP) exit criteria and FT licence conditions
Need to embed accountability framework and improve performance culture

Mitigating actions (what have we done/what more should we do?)

Improvement programme phase 2 – local governance work on-going as part of Quality & Safety pillar, but with new delivery board chaired by CEO supported by workstreams, care group workshops to better engage and inject more pace, plus additional support from NHSE. Recruitment for local governance programme lead October 2023

Strategic Objective 3 – Transforming Lives
Risk Description 3.1 Risk of failure to gain and sustain the confidence of the service users, partners, other stakeholders and public Risk Appetite – the Trust has an open risk appetite in gaining the trust and confidence of our service users, partners and wider public	Date last reviewed: September 2023	Director Lead: Stuart Richardson CEO	Board Committee: Board
Consequence of risk: If the Trust fails to gain the confidence of stakeholders this impacts on ability to transform and improve services in partnership, on CQC rating and RSP and financial sustainability	Risk Rating over time NEW BAF	Rationale for current score: (l x c) Work with partners to improve learning from deaths and addressing remaining CQC must dos. High Risk 4 x 4 = 16
Target Rating: (l x c) and Date to reach target 2 x 4 = 8 March 2024
Controls (what are we currently doing about the risk?) Trust Improvement Programme, pillar work. N&W chairing Evidence Assurance Group (EAG) which signs of CQC must dos NSFT is active partner of Norfolk & Waveney and Suffolk & North East Essex ICBs MH collaboratives and EoE Provider Collaborative Improvement programme work with system partners – external members of Improvement board Working with regional and national MH Trusts. Regional and system colleagues attend Quality Assurance Committee, Performance & Finance Committee and participate in Quality & Safety Reviews Experience of Care Committee with partners, service users, Healthwatch Delivery Group overseeing Grant Thornton report action plan and work with wider system on improving learning from deaths and addressing health inequalities Joint Board Medical Staffing Committee meetings	Assurances (how do we know if the things we are doing are having impact?) Improvements highlighted by CQC report published February 2023. Overall rating improved to ‘Requires Improvement’. No enforcement notices. Progress with Improvement programme phase 2 with partners – Improvement Board monitors metrics. But Trust remains in Recovery Support Programme (RSP) Established MH collaboratives with SNEE and N&W. Positive progress with east of England provider collaborative performance metrics. Grant Thornton UK LLP’s audit of the processes the Trust uses to collect and report mortality data identified insufficient clarity and consistency in the categorising and grouping of expected and unexpected deaths. Urgent action is underway to address these issues recognising the importance of timely, accurate mortality data for the Trust's learning, and for those families, carers and loved ones of all patients who have sadly died. Progress on actions reviewed at each Joint Board MSC meeting
Gaps Remaining CQC must dos and ensuring sustainable change Trust remains in recovery support programme (RSP) Medical Engagement Implement Grant Thornton audit recommendations and coproduce action plan for further improvement with partners	Mitigating actions (what have we done/what more should we do?) System partners part of Improvement programme pillar groups and check and challenge via EAG and Improvement Board Established RSP group with NED chair reviewing evidence of RSP criteria On-going engagement with medical staff – regular Board meeting with MSC. Clinical Senate established and meeting regularly. Medical admin review underway; addressing key vacancies. Model of Care work. Engaging medical colleagues with restructure

Strategic Objective 3 – Transforming Lives

Risk Description 3.1 Risk of failure to gain and sustain the confidence of the service users, partners, other stakeholders and public

Risk Appetite – the Trust has an open risk appetite in gaining the trust and confidence of our service users, partners and wider public

Date last reviewed:

September 2023

Director Lead: Stuart Richardson CEO

Board Committee:

Board

Consequence of risk:

If the Trust fails to gain the confidence of stakeholders this impacts on ability to transform and improve services in partnership, on CQC rating and RSP and financial sustainability

Risk Rating over time

NEW BAF

Rationale for current score: (l x c)

Work with partners to improve learning from deaths and addressing remaining CQC must dos.

High Risk 4 x 4 =

Target Rating: (l x c) and Date to reach target

2 x 4 = 8 March 2024

Controls (what are we currently doing about the risk?)

Trust Improvement Programme, pillar work. N&W chairing Evidence Assurance Group (EAG) which signs of CQC must dos
NSFT is active partner of Norfolk & Waveney and Suffolk & North East Essex ICBs MH collaboratives and EoE Provider Collaborative
Improvement programme work with system partners – external members of Improvement board
Working with regional and national MH Trusts. Regional and system colleagues attend Quality Assurance Committee, Performance & Finance Committee and participate in Quality & Safety Reviews
Experience of Care Committee with partners, service users, Healthwatch
Delivery Group overseeing Grant Thornton report action plan and work with wider system on improving learning from deaths and addressing health inequalities
Joint Board Medical Staffing Committee meetings

Assurances (how do we know if the things we are doing are having impact?)

Improvements highlighted by CQC report published February 2023. Overall rating improved to ‘Requires Improvement’. No enforcement notices.
Progress with Improvement programme phase 2 with partners – Improvement Board monitors metrics. But Trust remains in Recovery Support Programme (RSP)
Established MH collaboratives with SNEE and N&W. Positive progress with east of England provider collaborative performance metrics.
Grant Thornton UK LLP’s audit of the processes the Trust uses to collect and report mortality data identified insufficient clarity and consistency in the categorising and grouping of expected and unexpected deaths. Urgent action is underway to address these issues recognising the importance of timely, accurate mortality data for the Trust's learning, and for those families, carers and loved ones of all patients who have sadly died.
Progress on actions reviewed at each Joint Board MSC meeting

Gaps

Remaining CQC must dos and ensuring sustainable change
Trust remains in recovery support programme (RSP)
Medical Engagement
Implement Grant Thornton audit recommendations and coproduce action plan for further improvement with partners

Mitigating actions (what have we done/what more should we do?)

System partners part of Improvement programme pillar groups and check and challenge via EAG and Improvement Board
Established RSP group with NED chair reviewing evidence of RSP criteria
On-going engagement with medical staff – regular Board meeting with MSC. Clinical Senate established and meeting regularly. Medical admin review underway; addressing key vacancies. Model of Care work. Engaging medical colleagues with

restructure

Strategic Objective – Creating the conditions and environment to achieve
Risk Description 4.1 Risk of lack of access to timely and good quality data to enable effective decision-making and improvement. Risk Appetite: The Trust has a very low/averse appetite based on the impact of poor data quality on quality, safety and patient experience.	Date last reviewed: September 2023	Director Lead: Thandie Matambanadzo, Chief Operating Officer	Board Committee: Performance and Finance Committee
Consequence of risk: If data quality is poor, then this negatively impacts our ability to provide meaningful and accurate information to enable effective decision making and safe services for our services users and performance management information	Risk Rating over time New BAF	Rationale for current score: (l x c): Better scrutiny and continued improvement with data quality but more work needed on clinical support and inputting on Lorenzo for accurate recording. High Risk 4 x 4 = 16
Target Rating: (l x c) and Date to reach target Target rating 3 x 3 by March 2025
Controls (what are we currently doing about the risk?) Integrated quality and performance report (IQPR) The performance and business change teams manage Standard Operating Procedures (SOPs) related to data entry on Lorenzo. Check and challenge at local governance meetings and then at quality and performance meetings (QPMs). Access, data and delivery improvement programme pillar work Guides and team support for using Lorenzo. Electronic patient record (EPR) re-procurement commenced with clinical engagement and programme management support Training teams on Making Data count, PowerBI etc As part of work to reduce waiting lists, a uniform template has been developed/deployed in the case of those service users waiting 52 weeks or more for referral to assessment or treatment.	Assurances (how do we know if the things we are doing are having impact?) Regular reports on data quality to performance and finance committee alongside IQPR IQPR continues to develop and is routinely being used for analysis and decision- making about improvement priorities and is leading to demonstrable data quality improvements and highlighting specific data quality issues at service level. Improved QPMs, with NED attendance, providing a mechanism for checking, challenging and supporting care group leadership teams to deliver on quality and performance objectives including improving data quality. However, there is more to do to ensure that local governance meetings and systems are aligned to ensure ‘floor to board’ reporting at service level. The Trust remains unable to provide real-time data as part of its IQPR due to the constraints of data not all being contained within a single data warehouse.
Gaps Lack of robust data validation plans across challenges services. Data and information being generated locally rather than from centrally managed data sources could lead to inconsistencies. Dashboards at team level.	Mitigating actions (what have we done/what more should we do?) A data quality strategy is being prepared, as part of pillar work, with plans to present to the executive group and onwards to the performance and finance committee in November 2023. Concurrently, development of a data-stewardship programme is underway as an enabler to delivering the new strategy. This work will be supported by bringing multi-

Strategic Objective – Creating the conditions and environment to achieve

Risk Description 4.1 Risk of lack of access to timely and good quality data to enable effective decision-making and improvement.

Risk Appetite: The Trust has a very low/averse appetite based on the impact of poor data quality on quality, safety and patient experience.

Date last reviewed:

September 2023

Director Lead: Thandie Matambanadzo, Chief

Operating Officer

Board Committee:

Performance and Finance Committee

Consequence of risk:

If data quality is poor, then this negatively impacts our ability to provide meaningful and accurate information to enable effective decision making and safe services for our services users and performance

management information

Risk Rating over time

New BAF

Rationale for current score: (l x c):

Better scrutiny and continued improvement with data quality but more work needed on clinical support and inputting on Lorenzo for accurate recording.

High Risk 4 x 4 =

Target Rating: (l x c) and Date to reach target

Target rating 3 x 3 by March 2025

Controls (what are we currently doing about the risk?)

Integrated quality and performance report (IQPR)
The performance and business change teams manage Standard Operating Procedures (SOPs) related to data entry on Lorenzo.
Check and challenge at local governance meetings and then at quality and performance meetings (QPMs).
Access, data and delivery improvement programme pillar work
Guides and team support for using Lorenzo.
Electronic patient record (EPR) re-procurement commenced with clinical engagement and programme management support
Training teams on Making Data count, PowerBI etc
As part of work to reduce waiting lists, a uniform template has been developed/deployed in the case of those service users waiting 52 weeks or more for referral to assessment or treatment.

Assurances (how do we know if the things we are doing are having impact?)

Regular reports on data quality to performance and finance committee alongside IQPR
IQPR continues to develop and is routinely being used for analysis and decision- making about improvement priorities and is leading to demonstrable data quality improvements and highlighting specific data quality issues at service level.
Improved QPMs, with NED attendance, providing a mechanism for checking, challenging and supporting care group leadership teams to deliver on quality and performance objectives including improving data quality. However, there is more to do to ensure that local governance meetings and systems are aligned to ensure ‘floor to board’ reporting at service level.
The Trust remains unable to provide real-time data as part of its IQPR due to the constraints of data not all being contained within a single data warehouse.

Gaps

Lack of robust data validation plans across challenges services.
Data and information being generated locally rather than from centrally managed data sources could lead to inconsistencies.
Dashboards at team level.

Mitigating actions (what have we done/what more should we do?)

A data quality strategy is being prepared, as part of pillar work, with plans to present to the executive group and onwards to the performance and finance committee in November 2023.
Concurrently, development of a data-stewardship programme is underway as an enabler to delivering the new strategy. This work will be supported by bringing multi-

More hands-on education and support and information on Lorenzo recording needed, including to support data migration and adoption of a new EPR.
Development of a data quality strategy including definitions, standards and methods of engagement staff in improvements
There is a need for SOPs to be complemented by education/training packages and regular check and challenge at every level to ensure that poor data entry is addressed at source.
There is a need to raise the profile of data quality issues across the Trust – for example, in the need to record patient contacts and outcomes accurately on the EPR.

disciplinary staff together as part of a “Data Quality Day” scheduled to take place on 18 October 2023.

Work to procure a new EPR is underway including support to develop a full business case and complete tendering process by Oct 2024. A programme director is being recruited to lead the changes. Stakeholder and executive panel interviews are scheduled to take place on 2 and 3 October respectively.
Work underway to better understand issues and implement change, in line with culture and EPR procurement programmes to remove dependence on locally held data (on-going, initiated in June 2023)
On-going work to align our reporting to new data warehouse. Continuing development of IQPR.
Data quality group working with business change to provide more intensive, targeted support (on-going, initiated May 2023).
Work is ongoing within care groups to undertake data validation work. As part of work to reduce waiting lists, a uniform template has been developed/deployed in the case of those service users waiting 52 weeks or more for referral to assessment or treatment.

Strategic Objective 4 – Creating the conditions and environment to achieve
Risk Description 4.2 Failure to maintain financial sustainability Risk Appetite – the Trust has a low appetite for risks that impact on financial sustainability, but moderate appetite where this helps deliver substantial benefits to service users and/or realises significant longer-terms efficiencies	Date last reviewed: September 2023	Director Lead: Jason Hollidge, CFO	Board Committee: Performance and Finance Committee
Consequence of risk: If the Trust is not able to maintain financial sustainability, then, it will not have sufficient funds to provide the services required to the population we serve, or be able to invest in service improvements in the future, or meet statutory financial duties leading to tighter external control	Risk Rating over time NEW BAF	Rationale for current score: (l x c) Submitted break-even plan for 2023/24, M5 performance in line with plan including break- even forecast out-turn, however, mitigations of the underlying overspend position are non- recurrent in nature High Risk 5 x 5 = 25
Target Rating: (l x c) and Date to reach target 1 x 4 = 4 March 2024
Controls (what are we currently doing about the risk?) Standing Financial Instructions and financial controls Budget manager sign off of start year budget, includes budget manager pledge. Monthly finance review with budget managers Refreshed Accountability & Performance Framework – need to embed Quality and Performance Meetings (QPMs) include financial performance; Inpatient Recovery check & challenge meeting with care groups Monthly scrutiny/challenge by Executive Scrutiny by Board Efficiency, Value and improvement (EVI) MDT group Monthly Capital Review Group (CRG) considers capital slippage/ new requirements.	Assurances (how do we know if the things we are doing are having impact?) Breaches to SFIs reported to A&RC. Annual refresh of SFIs with comms and training Integrated Quality Performance Report (IQPR) Use of Resources metrics reported to Performance & Finance Committee and Board, together with separate detailed Financial reporting, showing continued financial performance challenges Reports at QPMs and Inpatients Financial Recovery plan – not delivering the required savings to the run-rate expenditure – monthly recovery meetings in place with Care Group leadership, COO and CFO Target recurrent efficiency levels – full identification not yet completed – monthly check and challenge meetings between Exec sponsors, CEO, CFO Annual accounts given clean audit opinion for FY 22/23 Joint scrutiny and challenge with system partners including NED led scrutiny at N&W ICS Finance Committee and NHSE Regional CFO scrutiny as a member of the N&W system CRG oversight of capital budget with clinical prioritisation of spend
Gaps Lack of fully developed Trust Financial Strategy; Lack of accountability for financial management within the organisation following the prescriptive financial framework generated by the COVID response;	Mitigating actions (what have we done/what more should we do?) Accountability and Performance Framework launched (Oct 22) and revised QPM agenda and approach (Nov 22) focusing on holding teams to account for all aspects of performance, including Finance. Further robust challenge required at all levels (ongoing). Re-commitment from systems to continue to meet Mental Health Investment Standard (MHIS), confirmed again at meeting on 17/07/2023. Ongoing lobbying across

Strategic Objective 4 – Creating the conditions and environment to achieve

Risk Description 4.2 Failure to maintain financial sustainability

Risk Appetite – the Trust has a low appetite for risks that impact on financial sustainability, but moderate appetite where this helps deliver substantial benefits to service users and/or realises significant longer-terms efficiencies

Date last reviewed:

September 2023

Director Lead:

Jason Hollidge, CFO

Board Committee:

Performance and Finance Committee

Consequence of risk:

If the Trust is not able to maintain financial sustainability, then, it will not have sufficient funds to provide the services required to the population we serve, or be able to invest in service improvements in the future, or meet statutory

financial duties leading to tighter external control

Risk Rating over time

NEW BAF

Rationale for current score: (l x c)

Submitted break-even plan for 2023/24, M5 performance in line with plan including break- even forecast out-turn, however, mitigations of the underlying overspend position are non- recurrent in nature

High Risk 5 x 5 =

Target Rating: (l x c) and Date to reach target

1 x 4 = 4 March 2024

Controls (what are we currently doing about the risk?)

Standing Financial Instructions and financial controls
Budget manager sign off of start year budget, includes budget manager pledge. Monthly finance review with budget managers
Refreshed Accountability & Performance Framework – need to embed
Quality and Performance Meetings (QPMs) include financial performance;
Inpatient Recovery check & challenge meeting with care groups
Monthly scrutiny/challenge by Executive
Scrutiny by Board
Efficiency, Value and improvement (EVI) MDT group
Monthly Capital Review Group (CRG) considers capital slippage/ new requirements.

Assurances (how do we know if the things we are doing are having impact?)

Breaches to SFIs reported to A&RC. Annual refresh of SFIs with comms and training
Integrated Quality Performance Report (IQPR) Use of Resources metrics reported to Performance & Finance Committee and Board, together with separate detailed Financial reporting, showing continued financial performance challenges
Reports at QPMs and Inpatients Financial Recovery plan – not delivering the required savings to the run-rate expenditure – monthly recovery meetings in place with Care Group leadership, COO and CFO
Target recurrent efficiency levels – full identification not yet completed – monthly check and challenge meetings between Exec sponsors, CEO, CFO
Annual accounts given clean audit opinion for FY 22/23
Joint scrutiny and challenge with system partners including NED led scrutiny at N&W ICS Finance Committee and NHSE Regional CFO scrutiny as a member of the N&W system
CRG oversight of capital budget with clinical prioritisation of spend

Gaps

Lack of fully developed Trust Financial Strategy;
Lack of accountability for financial management within the organisation following the prescriptive financial framework generated by the COVID response;

Mitigating actions (what have we done/what more should we do?)

Accountability and Performance Framework launched (Oct 22) and revised QPM agenda and approach (Nov 22) focusing on holding teams to account for all aspects of performance, including Finance. Further robust challenge required at all levels (ongoing).
Re-commitment from systems to continue to meet Mental Health Investment

Standard (MHIS), confirmed again at meeting on 17/07/2023. Ongoing lobbying across

Strategic Objective 4 – Creating the conditions and environment to achieve
Risk Description 4.3 Risk of failure to deliver Rivers Centre new build Risk Appetite – the Trust has a moderate appetite to the new build	Date last reviewed: September 2023	Director Lead: Stuart Richardson	Committee: Performance & Finance Committee
Consequence of risk: If we fail to build and deliver the new Rivers Centre build on time, on budget and without appropriate therapeutic environment, this impacts on our ability to deliver quality of care, reduce out of area and reputation impact	Risk Rating over time NEW BAF	Rationale for current score: (lxc) Maintaining risk score whilst work progresses Significant Risk 3 x 5 = 15
Date to reach Target Rating: (l x c) long term risk, expect to reduce risk at each gateway approval stage - 1 x 3 = September 2024
Controls (what are we currently doing about the risk?) Robust project management/governance; NHSE/ICS on Project Board. SRO is CEO, supported by Director of Estates and programme leads Wide stakeholder co-production of build design and throughout project Monthly financial reviews, reporting to Project Board. All change request forms reviewed by CFO. Utilisation of framework contracts and Trust procurement support. Regular review by Council of Governors Significant Business Committee. Stakeholder engagement throughout project	Assurances (how do we know if the things we are doing are having an impact?) NHSE scrutiny as part of Project Board Performance of P22 construction partner against programme of works

Strategic Objective 4 – Creating the conditions and environment to achieve

Risk Description 4.3 Risk of failure to deliver Rivers Centre new build

Risk Appetite – the Trust has a moderate appetite to the new build

Date last reviewed:

September 2023

Director Lead:

Stuart Richardson

Committee:

Performance & Finance Committee

Consequence of risk:

If we fail to build and deliver the new Rivers Centre build on time, on budget and without appropriate therapeutic environment, this impacts on our ability to deliver quality of care, reduce out of area and reputation impact

Risk Rating over time

NEW BAF

Rationale for current score: (lxc)

Maintaining risk score whilst work progresses

Significant Risk 3 x 5 =

Date to reach Target Rating: (l x c)

long term risk, expect to reduce risk at each gateway approval stage - 1 x 3 = September 2024

Controls (what are we currently doing about the risk?)

Robust project management/governance; NHSE/ICS on Project Board. SRO is CEO, supported by Director of Estates and programme leads
Wide stakeholder co-production of build design and throughout project
Monthly financial reviews, reporting to Project Board.
All change request forms reviewed by CFO.
Utilisation of framework contracts and Trust procurement support.
Regular review by Council of Governors Significant Business Committee. Stakeholder engagement throughout project

Assurances (how do we know if the things we are doing are having an impact?)

NHSE scrutiny as part of Project Board
Performance of P22 construction partner against programme of works

RISK MATRIX	Likelihood
Consequence	1 – Rare	2 - Unlikely	3 – Possible	4 – Likely	5 – Almost Certain
1 – Negligible	1	2	3	4	5
2 – Minor	2	4	6	8	10
3 – Moderate	3	6	9	12	15
4 – Major	4	8	12	16	20
5 - Catastrophic	5	10	15	20	25

High Risk	15 to 25	Immediate action must be taken to manage the risk. Control measures should be put into place immediately to reduce the consequence of the risk or the likelihood of it occurring. A number of control measures may be required and significant resources may be needed
Significant Risk	8 to 12	Efforts should be made to reduce the risk as soon as practicably possible, weighing up migitation resources/changes against the consequence of the risk in line with the Trust's risk appetite and the nature of the risk
Moderate Risk	4 to 6	Check the likelihood of harm and review existing controls - can small changes easily be made to manage the risk? Keep reassessing the risk to ensure it doesn’t worsen
Low risk	1 to 3	Acceptable risk, no further action or additional controls are required. A risk at this level should be monitored and reassessed at appropriate intervals to ensure that it hasn’t worsened

High Risk

15 to 25

Immediate action must be taken to manage the risk. Control measures should be put into place immediately to reduce the consequence of the risk or the likelihood of it occurring. A number of control measures may be required and significant resources may be needed

Significant Risk

8 to 12

Efforts should be made to reduce the risk as soon as practicably possible, weighing up migitation resources/changes against the consequence of the risk in line with the Trust's risk appetite and the nature of the risk

Moderate Risk

4 to 6

Check the likelihood of harm and review existing controls - can

small changes easily be made to manage the risk? Keep reassessing the risk to ensure it doesn’t worsen

Low risk

1 to 3

Acceptable risk, no further action or additional controls are required. A risk at this level should be monitored and reassessed at appropriate intervals to ensure that it hasn’t worsened