ENCLOSURE N
Paper WL895
WEST LONDON MENTAL HEALTH NHS TRUST
ASSURANCE FRAMEWORK 2005/6 Q3 UPDATE
REPORT FROM THE DIRECTOR OF STRATEGY & PERFORMANCE
This paper supports Healthcare Standards reference C7a and C7c.
The Board is asked to review the Assurance Framework and satisfy itself the Trust’s
corporate objectives, risks to their achievement and mitigating actions are accurately
reflected within the document and that the principal risks are being adequately
managed.
1 INTRODUCTION
1.1 The Assurance Framework is a mandatory NHS document which identifies risks to
the achievement of the Trust’s corporate objectives and mitigating controls. It
supports the requirement of the Chief Executive as the Accountable Officer for the
Trust to sign the annual Statement of Internal Control (SIC) and the Final Declaration
of Compliance with Standards for Better Health.
1.2 The Board is asked to review the attached Assurance Framework, which has been
reviewed and updated by the Executive Directors and satisfy itself that this
represents a true reflection of the way in which the principal risks of the organisation
are being managed.
1.3 Highlighted below for the Board’s information are:
additions to the Assurance Framework during Quarter 3 2005/6 i.e. newly
identified/emerging risks to achievement of the Trust’s 2005/6 corporate
objectives;
changes to the assessment of the likelihood and/or impact of the risk to
achievement of the objective; and
summary of those risks rated as ‘red’ i.e. where a control cannot entirely mitigate
a risk or where the impact of the control’s failure would have a significant impact
on the delivery of the Trust’s objectives.
1.4 There were no risks removed the Assurance Framework during this quarter.
2 ADDITIONS TO THE ASSURANCE FRAMEWORK DURING QUARTER 3 2005/6
2.1 Risks added to the Assurance Framework during Q3 2005/6:
S1.11.2 Asbestos contamination identified in surveys prior to capital
work being undertaken - Red / High
S1.13.1 Disruption to Trust wide services due to Flu Pandemic - Green
/ High
C1.9.3 Inadequate skills for DSPD Unit - Amber / Moderate
C1.10.1 Clarification of patient numbers and funding sources to transfer
into the new WEMMS Service - Amber / High
G3.1.12 Inability to develop Trust [ICT] infrastructure due to asbestos in
D block tunnel - Red / High
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3 CHANGES TO THE ASSURANCE FRAMEWORK DURING QUARTER 3 2005/6
3.1 Changes to status of Risk during Q3 2005/6:
S1.11.1 Untrained staff re compliance to fire regulations - Amber to
Green
C1.9.2 Sufficient allocated capital for DSPD Unit - Amber to Green
G2.1.3 Shortage of cash in the NHS - Red to Amber
E1.2.1 Inadequate design within available resources for new
developments - Amber to Green
4 SUMMARY OF ‘RED’ RATED RISKS
HCC Domain Risk Commentary
Safety S1.10.1 Insufficient funding Improved capital allocation to Trust for
for maintenance 2006/7 should help to ease this situation.
S1.11.2 Asbestos With implementation of controls risk of
Contamination asbestos contamination should be
substantially reduced.
Governance G2.1.2 Expenditure budgets Breakeven predicted for yearend,
in excess of income expenditure controls operating effectively.
projections in approved
budgets. Significant level of
unidentified savings.
G2.2.2 Major capital funds See S1.10.1 above.
brokered to Operational in
past periods
G3.1.2 Lack of computer Project plan to recruit trainers etc. on
literacy amongst clinical schedule, remaining risk is attendance of
frontline staff clinical staff at training, mitigation for this is
within plan to roll-out training.
G3.1.4 Delivery and Approval of Rio Business Case on March
implementation of the IT 2006 Board agenda.
solution for mental health
G3.1.7 Access / security As G3.1.4 above. Implementation of Rio
controls security controls
G3.1.8 Corporate wide Intranet supplier identified, project being
dissemination and collation of delivered on schedule.
information
G3.1.11 Inadequate Rollout of XP 50% complete, project plan
hardware / network for hardware/network delivery on schedule.
G3.1.12 Inability to develop Risk to project timelines.
Trust infrastructure due to
asbestos in D block tunnel
G4.7.1 Blame culture and Whistleblowing policy on March Board
fear of whistle blowing agenda for approval.
Accessible & A1.2.1 Lack of suitable Adult and CAMH services currently
responsive inpatient accommodation for developing protocol for admission of
care adolescents adolescents to adult wards where
necessary/appropriate. PCTs monitor
standard of out of area placements.
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4.1 In summary, the number of ‘red’ rated risks has increased by 1 during the quarter to
13 out of 118 identified and rated risks.
5 CONCLUSION & RECOMMENDATION
5.1 In November 2005 the Trust Board approved the Trust’s proposed corporate
objectives for 2006/07 and inclusion in the business planning process for 2006/7
work to align the Trust’s corporate objectives more closely to the Standards for Better
Health and to the Healthcare Commission’s Annual Health Check to form an
integrated business plan. The March 2006 Business Plan Board paper re-iterates
these objectives and outlines the proposed framework for monitoring and
management of delivery against the plans during the year.
5.2 Following on from this, the whole Board will need to update the full Assurance
Framework based on the revised corporate objectives for 2006/7, and ensuring that
links to the performance management framework and reporting structures and from
the corporate risk register are explicitly established.
5.3 The Board is asked to review the complete Assurance Framework and satisfy
itself that this represents a true reflection of the way in which the principal
risks of the organisation are being managed.
Lesley Stephen
Director of Strategy and Performance
March 2006
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