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					                                                             ROYAL CORNWALL HOSPITAL NHS TRUST
                                                                           2009/10
                                                          BOARD ASSURANCE FRAMEWORK (OCTOBER 2009)
Risk Principal Risks by Key    Risk      Actual   Lead Director         Key Controls              Assurances on Controls            Gaps in Controls and Actions           Gaps in Assurances and Actions
Ref          Areas           Scoring      Risk     Accountable   What controls / systems are      Where do we gain proof /        Where are we failing to put effective        Where we are failing to gain
     What could prevent this Impact      Impact         for     in place to secure delivery of    outcomes our controls are      controls/systems in place? What action   assurance/proof that the controls are
         objective being        X          X      management            the objective?                   effective?                           needs taking?               effective? What action needs taking?
           achieved?        Likelihood Likelihood     of risk




Overarching Objective - MORE TIMELY AND EFFECTIVE CARE


                      Objective 1) To achieve all national and local access targets while delivering contracted activity levels.

 1a   Capacity not aligned      4x4        4x3         Chief      1. Development of recovery    Integrated Board                None identified                           None identified
      with demand and good      = 16       = 12       Operating   plans that ensure capacity is Performance Report
      patient experience.       red       amber        Officer    in place to deliver national  monthly.
                                                                  access targets; aligned with
      S4BH - C7f -                                                service Improvement
      declaration n/a;                                            Programmes. Action: Update
      assessed by other                                           09.10.09 Manager. seconded
      measures                                                    to lead work reporting to
      C19 - declaration n/a;                                      Service Improvement
      assessed by other                                           Programme Manager
      measures
                                                                   2. Effective monitoring to   Weekly performance              None identified                           None identified
                                                                  ensure variances in capacity dashboard
                                                                  and in demand are managed
                                                                  proactively. Action: Improved
                                                                  information and performance
                                                                  management arrangements in
                                                                  place through COO weekly
                                                                  performance meeting.


                                                                  3. Improved data quality of    2 x Annual internal audit on   Further development of leading indicators None identified
                                                                  waiting lists.                 waiting list management.       as part of the Business Intelligence Unit,
                                                                                                 Weekly progress report         Jan 2010.
                                                                                                 scrutiny by PCT and DOH
                                                                                                 Intensive support team
                                                                  4. An operational              Monitoring of Divisional       Capacity and demand work will be fully    Board sign off on 2009/10
                                                                  demand/capacity model has      Recovery Plan                  integrated into the 2009/10 Business      organisational plan
                                                                  been developed.                implementation; weekly         Planning round.
                                                                                                 enquiry.
                                                                                                                                                                                                         1
Risk Principal Risks by Key    Risk      Actual                         Key Controls                                        Gaps
                                                  Lead Director ROYAL CORNWALL Assurances on Controls TRUST in Controls and Actions
                                                                                                HOSPITAL NHS                                                                                Gaps in Assurances and Actions
Ref          Areas           Scoring      Risk     Accountable   What controls / systems are    Where do we gain proof /  Where are we failing to put effective                                 Where we are failing to gain
     What could prevent this Impact      Impact         for     in place to secure delivery of2009/10 our controls are
                                                                                                outcomes                 controls/systems in place? What action                            assurance/proof that the controls are
         objective being        X          X              BOARD ASSURANCE FRAMEWORK (OCTOBER 2009) taking?
                                                  management            the objective?                 effective?                     needs                                                effective? What action needs taking?
           achieved?        Likelihood Likelihood     of risk


                                                                                 5. Review of the Patient       Agreed Action Plan in place, None identified                               Choose and Book performance is the
                                                                                 Administration and Booking     accountable directly to COO.                                               subject of an agreed recovery plan
                                                                                 function.                      Indicators include reduction                                               developed in conjunction with the
                                                                                                                in short notice clinics and                                                PCT, to be monitored at monthly
                                                                                                                cancellation of clinics,                                                   PCT/Trust performance reviews.
                                                                                                                improved Choose and Book
                                                                                                                performance and matching
                                                                                                                capacity to demand.
                                                                                                                Monitored weekly through
                                                                                                                the COO performance
                                                                                                                Group.

1b    Incomplete delivery of           4x3        4x2        Dir of Health 1. The Health Informatics            1. Through the success of   None identified                                1. Escalation route yet to be agreed
      the Health Informatics           = 12       =8              Info     Programme Board ensures              the individual projects and                                                from these Informatics Boards.
      Development                     amber      amber                     that the right decisions are         therefore the programme as                                                 Action: R. Johnson / HIP Board
      Programme                                                            made on Informatics                  a whole.
                                                                           developments.
      S4BH - D6 -
      Developmental                                                              2. Ensure adequate capital     2. See above (1)              2. Increasing concern at indications that 1. Escalation route yet to be agreed
      Standard                                                                   and revenue budgets are                                      the capital budget will be inadequate to  from these Informatics Boards.
                                                                                 allocated to the programmes                                  deliver on the programme as set out. This Action: R. Johnson / HIP Board
                                                                                                                                              is being pursued with the Director of
                                                                                                                                              Finance. October 2009.


 1c   National Programme fails to     5x3 = 15   5x2 = 10   Dir of Health Info   1. Existing supplier, EDS,    1. Appropriate duration of     1. Uncertainty in future of support due to   1. Escalation route yet to be agreed
      deliver according to national                                              continues to supported legacy contract, at acceptable price, lack of monies to invest in development.     from these Informatics Boards
                                        red       Amber
      and local plans
                                                                                 systems (especially PAS)      in place.


      S4BH - D6 - Developmental
      Standard                                                                   TO                             BE                             DELETED

1d    National Programme to            4x5       4x2=8      Acting Director      1. EMSA Programme Board -
      deliver same sex                 = 20       yellow     of Nursing,         developed programme of
      accommodation (DSSA)             red                   Midwifery &         work, overseeing and
                                                                 AHPs            monitoring progress. EMSA
                                                                                 Programme Board closed.

      S4BH - C20b - non-                                                         1. DSSA Operational Group      1.1 Minutes of DSSA           1.1 DSSA Operational Group - first           1.1 No minutes yet as first meeting in
      compliant 08/09                                                                                           Programme Board.              meeting in October.                          October.


                                                                                                                1.2 Bi-monthly update report None identified                               1.2 First report to November
                                                                                                                to Divisional quality Group.                                               Divisional Quality Group
                                                                                                                                                                                                                           2
                                                       AHPs


     Principal Risks by
Risk S4BH - C20b - non-Key     Risk      Actual   Lead Director ROYAL CORNWALL Assurances on Controls TRUST in Controls and Actions
                                                                        Key Controls                                        Gaps
                                                                                                HOSPITAL NHS                                                                  Gaps in Assurances and Actions
             Areas
Ref compliant 08/09          Scoring      Risk     Accountable   What controls / systems are    Where do we gain proof /  Where are we failing to put effective                   Where we are failing to gain
     What could prevent this Impact      Impact         for     in place to secure delivery of2009/10 our controls are
                                                                                                outcomes                 controls/systems in place? What action              assurance/proof that the controls are
         objective being        X          X              BOARD ASSURANCE FRAMEWORK (OCTOBER 2009) taking?
                                                  management            the objective?                 effective?                     needs                                  effective? What action needs taking?
           achieved?        Likelihood Likelihood     of risk


                                                                  2. Action plan to DSSA.          2.1 Progress reported           2.1 Action plan still being developed     2.1 Action plan still being developed -
                                                                                                   against action plan.                                                      completion date for first draft 17.10.09
                                                                                                                                                                             following conference call with DH.

                                                                  3. Dignity in Care Policy.       3.1 Privacy in Dignity EOC      3.1 Dignity in care policy due for        None identified
                                                                                                   bench marking.                  ratification in October.
                                                                                                   3.2 Monthly privacy and         None identified                           None identified
                                                                                                   dignity nursing metric audit.

                                                                                                   3.3 Monthly breach report       None identified                           None identified
                                                                                                   from DATIX

                                                                                                   3.4 New nursing "metrics"       None identified                           3.4 first Nursing Metrics sign-off
                                                                                                   meeting.                                                                  meeting scheduled for mid October.

 1e   Lack of theatre capacity   3x4 = 12   3x3 = 9    Chief      Appointment of List broker       Improved theatre efficiency;    Lack of good information & dedicated      Update 09.10.09 BIAU formed.
      for key specialties e.g.    amber     amber     Operating   and establishment of group in    weekly performance meeting      information analysts hampers              Information team and performance
      gynae, orthopaedics.                             Officer    place to monitor and make        interpreted Performance         understanding of the problem. Urgent      manager working to develop reporting
                                                                  weekly reconciliation theatre    Report to Board.                need for additional analytical support.   metrics using Galaxy theatre systems
                                                                  use to address inefficiencies.                                   Update 09.10.09 Business Information
                                                                                                                                   and Assurance Unit established. New
                                                                                                                                   Galaxy theatre system introduced.
                                                                  Theatre capacity and demand                                      Recovery plan (see 1a).                   Recovery Plan (see 1a)
      S4BH - C7f -                                                included in capacity and
      declaration n/a                                             demand analysis and
      assessed by other                                           integrated with Division
      measures                                                    recovery plans.

                                                                  Service Improvement              Monitoring of progress via      None identified                           None identified
                                                                  Programme includes               Integrated Performance
                                                                  increasing theatre               Report.
                                                                  productivity.
                                                                  Business plan for T and A        2.1 Monitoring of progress   None identified                              None identified
                                                                  includes additional allocation   via programme board.
                                                                  for increased staffing levels    Funding agreed for
                                                                  for 09/10.                       additional anaesthetists and
                                                                                                   OPA's.
 1f   Failure to agree           4x4= 16    4x3= 12    Chief       Revised Getting Patients        Via GPT meeting once            GPT established.                          Assurance identifies lack of progress
      appropriate care             red       amber    Operating   Treated group will address       established. Monthly                                                      across GPT programme. Trust
      pathways with PCT                                Officer    cross cutting themes with        performance reviews with                                                  Services developing plans to present
      e.g.. Oral surgery and                                      PCT. Also will be reviewed as    PCT and SHA seek                                                          to PCT.
      ophthalmology in order                                      part of Divisional performance   adequate assurances.
      to contain demand.                                          reviews.
      S4BH - C6 - compliant
      08/09                                                                                                                                                                                                   3
Risk Principal Risks by Key    Risk      Actual                         Key Controls                                        Gaps
                                                  Lead Director ROYAL CORNWALL Assurances on Controls TRUST in Controls and Actions
                                                                                                HOSPITAL NHS                                                                        Gaps in Assurances and Actions
Ref          Areas           Scoring      Risk     Accountable   What controls / systems are    Where do we gain proof /  Where are we failing to put effective                         Where we are failing to gain
     What could prevent this Impact      Impact         for     in place to secure delivery of2009/10 our controls are
                                                                                                outcomes                 controls/systems in place? What action                    assurance/proof that the controls are
         objective being        X          X              BOARD ASSURANCE FRAMEWORK (OCTOBER 2009) taking?
                                                  management            the objective?                 effective?                     needs                                        effective? What action needs taking?
           achieved?        Likelihood Likelihood     of risk


1g    Poor management of          4x4 = 16    4x4= 16      Chief        Weekly performance           Through weekly                   Implementation of a new ED system and        1. Further work required with PCT and
      patient flow leading to       red         red       Operating    dashboard gives early signal performance reports and           discharge system will improve flow           adult social care to reduce
      outlying on surgical                                 Officer     of problems. Daily bed        monthly reports to Board.        through increased transparency and           inappropriate admissions and delayed
      wards and delayed                                                meetings and daily dashboard                                   availability of information real time.       discharge.
      transfers of care                                                alert to daily problems                                        Evolving Clinical Site Development Plan
                                                                       supported by escalation                                        predicated on key clinical adjacencies
      S4BH - C7f -                                                     plans. Monthly Directors of                                    and patient safety, improving patient flow
      declaration n/a;                                                 Operations meetings to                                         and efficiency. Pilot of single Front Door
      assessed by other                                                assess flow issues across                                      in Dec 09; will lead to reduced
      measures                                                         health and social care                                         admissions and length of stay.
                                                                       community. Patient flow
                                                                       project forms part of Service
                                                                       improvement programme




       Objective 2) To implement the Service Efficiency and Improvement Programme - working with the PCT to redesign patient
                         pathways to improve patient experience, clinical outcomes and the use of resources.

 2a   Failure to identify &        5x3       5x3      = Dir of Finance 1. Service Improvement          1.1 Minutes & agendas of       No gaps currently identified                 1.1 Whilst detailed and quantified
      implement a robust set       = 15          15                    leadership in place under the   Executive Management                                                        action plans are now in place across
      of service                   red          red                    direction of the Chief          Board.                                                                      the Trust to assure delivery of the
      improvements for the                                             Operating Officer. Executive                                                                                programme there remains a gap in
      Trust both in the current                                        Board review delivery of        1.2 Project Management                                                      Assurance to the Board as the
      year and future years                                            programme monthly.              plan for overall project.                                                   programme is £200,000 off target and
      resulting in potential                                           Divisional Finance Group                                                                                    with significant actions in the second
      WEAK use of resources                                            review programme monthly.       1.3. Project Initiation                                                     half of the year to be delivered.
      assessment, failure to                                                                           Documents for the individual                                                Assurance will only be improved with
      maximise value for                                                                               projects.                                                                   evidenced delivery. (JT/AM - ongoing
      money within the                                                                                                                                                             monthly).
      Cornish Health                                                                                   1.4 Milestones reports for
      Economy, & loss of                                                                               individual schemes.                                                         1.2 The board have requested
      confidence in Trust                                                                                                                                                          individual meetings with Divisions to
      Board from key external                                                                          1.5 Divisional Finance                                                      provide a further source of assurance.
      stakeholders.                                                                                    Meetings.                                                                   (JT/AM - October 2009).




                                                                                                                                                                                                                  4
Risk Principal Risks by Key    Risk      Actual                         Key Controls                                        Gaps
                                                  Lead Director ROYAL CORNWALL Assurances on Controls TRUST in Controls and Actions
                                                                                                HOSPITAL NHS                                                             Gaps in Assurances and Actions
Ref          Areas           Scoring      Risk     Accountable   What controls / systems are    Where do we gain proof /  Where are we failing to put effective              Where we are failing to gain
     What could prevent this Impact      Impact         for     in place to secure delivery of2009/10 our controls are
                                                                                                outcomes                 controls/systems in place? What action         assurance/proof that the controls are
         objective being        X          X              BOARD ASSURANCE FRAMEWORK (OCTOBER 2009) taking?
                                                  management            the objective?                 effective?                     needs                             effective? What action needs taking?
           achieved?        Likelihood Likelihood     of risk


     S4BH: D5b                                                   2. Integrated Performance     2.1. Routine risk assessed   2.1 As above                                2.1 As above.
     (not assessed as part                                       Reports to the Trust Board    reports to Board and
     of 08-09 declaration)                                       outlining progress on the     outlining progress against                                               2.2 Further assurance will be provided
                                                                 delivery of the Service       annual plan.                                                             to the Board when the internal audit
                                                                 Improvement Programme.                                                                                 review of the programme is complete.
                                                                                               2.2. Internal Audit annual                                               (JT - November 2009).
                                                                                               review of Service
                                                                                               Improvement plan scheduled
                                                                                               for 2009-10.

                                                                 3. Medium Term Financial      3. Medium Term Financial     3.1 An efficiency strategy approved 08-09   3 Until a fully integrated medium term
                                                                 Strategy and Recovery plan    Strategy.                    but a revised recovery plan & Trust wide    strategy is in place underpinned by
                                                                 sets out how the required                                  approach to the medium term needs to        financial, estates, service, capacity
                                                                 level of efficiency will be                                be established, documented & reported       and workforce plans, and a medium
                                                                 achieved beyond the current                                to Board as part of the strategy            term recovery plan, the Board do not
                                                                 financial year.                                            development process. Action: JT Q3 09-      have assurance actions are in place
                                                                                                                            10.                                         to ensure long term financial stability.
                                                                                                                                                                        Action to develop integrated plans to
                                                                                                                            3.2 Full integration with the MTFS of       be prioritised as part of the strategy
                                                                                                                            Estates, Workforce and Capacity             development process in 09-10.
                                                                                                                            strategies presently not in place. These    Action: J Teape/D Hastings/J Perry/A
                                                                                                                            documents should all be consistent & is     Murphy: Q3
                                                                                                                            an urgent requirement as the Trust
                                                                                                                            develop the clinical strategy in 09-10.
                                                                                                                            Action: J Teape/D Hastings/J Perry/A
                                                                                                                            Murphy:Q3
     S4BH: D5b                                                   4. Monthly Divisional         4. Monthly Divisional        No gaps currently identified                4. The majority of plans for Divisions
     (not assessed as part                                       performance reviews take      Reports                                                                  and Directors efficiency have been
     of 08-09 declaration)                                       place to review Divisional                                                                             received and are robust but until
                                                                 performance against                                                                                    delivery is evidenced, full assurance
                                                                 efficiency targets.                                                                                    cannot be confirmed. Remaining
                                                                                                                                                                        action is to finalise plans and
                                                                                                                                                                        evidence delivery. Action: J Teape/A
                                                                                                                                                                        Murphy. Ongoing.




                                                                                                                                                                                                         5
Risk Principal Risks by Key    Risk      Actual                         Key Controls                                        Gaps
                                                  Lead Director ROYAL CORNWALL Assurances on Controls TRUST in Controls and Actions
                                                                                                HOSPITAL NHS                                                                Gaps in Assurances and Actions
Ref          Areas           Scoring      Risk     Accountable   What controls / systems are    Where do we gain proof /  Where are we failing to put effective                 Where we are failing to gain
     What could prevent this Impact      Impact         for     in place to secure delivery of2009/10 our controls are
                                                                                                outcomes                 controls/systems in place? What action            assurance/proof that the controls are
         objective being        X          X              BOARD ASSURANCE FRAMEWORK (OCTOBER 2009) taking?
                                                  management            the objective?                 effective?                     needs                                effective? What action needs taking?
           achieved?        Likelihood Likelihood     of risk


2b    Failure to provide a       4x4      4x2      Acting Medical 1. Patient currently managed 1. Anaesthesia & Theatres        1. Business Case Required for Phase 1     1. Report adverse clinical events as
      centralised facility for   = 16     =8             Dir      by Critical Care Outreach to Management Team.                 of the Critical Site Development Plan.    part of Performance Review up to
      patients who fulfil the    red     amber                    mitigate the risk.                                                                                      Board Level. Action: Divisional
      need for Level 2 care                                                                                                                                               Directors.
      (High Dependency Unit)


      S4BH - C5a- Non                                             2. The Clinical Site             2. Mortality Review at       No gaps currently identified              No gaps currently identified
      Compliant 08/09                                             Development Plan has             Divisional Quality Board.
                                                                  identified level 2 care as an
                                                                  initial priority. Design work on
                                                                  the new facilities commenced
                                                                  Oct 09.
                                                                                                  3. Integrated Performance     No gaps currently identified              No gaps currently identified
                                                                                                  Board Report.

 2c   Pressure on Acute        4x5   =    4x3      Acting Medical 1. Divisions Monitor Medical 1. Division of Acute Medicine 1.Large numbers of emergency                 1. Reporting of Hospital Standardised
      Medical Beds leading to     20      = 12           Dir      Outliers and use of stroke   management team.              admissions continue to result in medical     Mortality Rate (HMSR) for emergency
      poor patient experience.   red     amber                    ward.                                                      outliers.                                    admissions as part of performance
                                                                  2. Appointment of Site                                                                                  review up to Board Level monthly.
      S4BH - C13a - Non                                           Services Manager - Beverley
      Compliant 08/09                                             Hales.
      C19 - declaration n/a;
      assessed by other
      measures




2d    Failure to optimise        4x4      4x2      Acting Medical 1. Appointment of a list broker 1. Divisional Management      1. Insufficient identified patient pathways. 1. Monthly performance review and
      theatre capacity.          = 16     =8             Dir      to optimise theatre             Team, Anaesthesia &           Action implementation of Phase 1 of the daily monitoring ; 18/52 action plan.
                                  red    amber                    throughput.                     Theatres.                     Clinical Site Development Plan.


                                                                  2. Managers on site to assist   2. Performance review.        No gaps currently identified              No gaps currently identified
                                                                  prompt start of operations.


 2e   Inappropriate case         5x4      5x2      Acting Medical 1. MEWS Triage in WCH           1. Mortality Review           1. Implementation of an evidence-based    1. Action implementation of guidelines
      selection for acute        = 20     =10            Dir      Casualty                        2. Critical Incident Review   risk assessment tool for Acute            1/12/09.
      admissions at West         red     amber                                                                                  Admissions to West Cornwall Hospital
      Cornwall Hospital.                                                                                                        agreed with PCT and SWAST.

      S4BH - C5a - Non
      compliant 08/09

                                                                                                                                                                                                          6
Risk Principal Risks by Key    Risk      Actual                         Key Controls                                        Gaps
                                                  Lead Director ROYAL CORNWALL Assurances on Controls TRUST in Controls and Actions
                                                                                                HOSPITAL NHS                                                                     Gaps in Assurances and Actions
Ref          Areas           Scoring      Risk     Accountable   What controls / systems are    Where do we gain proof /  Where are we failing to put effective                      Where we are failing to gain
     What could prevent this Impact      Impact         for     in place to secure delivery of2009/10 our controls are
                                                                                                outcomes                 controls/systems in place? What action                 assurance/proof that the controls are
         objective being        X          X              BOARD ASSURANCE FRAMEWORK (OCTOBER 2009) taking?
                                                  management            the objective?                 effective?                     needs                                     effective? What action needs taking?
           achieved?        Likelihood Likelihood     of risk


 2f   Lack of clinical buy into   5x3= 15   5x2= 10 Acting Medical 1. Regular review via the          1. Board minutes and          1. Clinical Leads unable to provide         1. Division Teams to engage in SIP
      Service Improvement           red      amber Director / CEO Board.                              Service Improvement           dedicated time due to clinical service      Programme. Action: Strengthen
      Programme.                                                                                      Programme minutes.            pressures. Action: Prioritise SIP work.     Divisional Management Teams Dec
                                                                                                                                                                                09.

      S4BH - C7b -                                                   1.1 Divisional work                                            No gaps currently identified                No gaps currently identified
      declaration n/a;                                               programme in place
      assessed by other                                              undergoes regular detailed
      measures                                                       review.

2g    Organisational learning     4x3 = 2x2    = Acting Director     1. Discharge/transfer outcome    1.1 TOR for new group         1.1 New group - first meeting arranged      1.1 New group - first meeting
      from compromised              12   4 Green of Nursing,         review group - alternate         1.2 Minutes from review       but not yet convened. First meeting held    arranged but not yet convened. First
      patient discharge /          Amber          Midwifery &        month review by joint acute,     group 1.3 Action plans -      in May. ToR in draft format for             meeting held May. ToR in draft format
      transfer outcomes                               AHPs           community and social care.       reviews and sign off on       consultation. Meeting dates for the         for consultation. Meeting dates for the
                                                                     Include pathway, processes,      completion (action plans      remainder of the being agreed.              remainder of the being agreed.
      S4BH - C13a - Non                                              documentation., monitoring of-
                                                                     2. Significant event meetings    from review group & RCAs)
                                                                                                      2.1 RCAs from significant     2.1 New initiative - nil required so far.   2.1 New initiative - nil required so far.
      compliant 08/09                                                ad hoc in response to            event meetings with ensuing
                                                                     individual cases.                action plan



                                                                     TO                               BE                            DELETED




                                                                                                                                                                                                                   7
Risk Principal Risks by Key    Risk      Actual                         Key Controls                                        Gaps
                                                  Lead Director ROYAL CORNWALL Assurances on Controls TRUST in Controls and Actions
                                                                                                HOSPITAL NHS                                                         Gaps in Assurances and Actions
Ref          Areas           Scoring      Risk     Accountable   What controls / systems are    Where do we gain proof /  Where are we failing to put effective          Where we are failing to gain
     What could prevent this Impact      Impact         for     in place to secure delivery of2009/10 our controls are
                                                                                                outcomes                 controls/systems in place? What action     assurance/proof that the controls are
         objective being        X          X              BOARD ASSURANCE FRAMEWORK (OCTOBER 2009) taking?
                                                  management            the objective?                 effective?                     needs                         effective? What action needs taking?
           achieved?        Likelihood Likelihood     of risk


2h   Proactive and Effective    4x5  = 4 x 2 = 8 Acting Director 1. PPI Steering Group          1.1 Minutes from the       No gaps currently identified            1.1 The organisation cannot currently
     Patient and Public         20 Red   amber    of Nursing,                                   Steering Group                                                     demonstrate inclusion of patients
     Involvement (PPI) in all                     Midwifery &                                                                                                      and/or the public in local development
     efficiency and                                   AHPs                                      1.2 Minutes from the                                               or strategic plans - to be discussed by
     improvement                                                                                Divisional Quality Group                                           EMT & strategy for inclusion
     programmes (both                                                                                                                                              developed. Consultation model
     ongoing planning of                                                                                                                                           devised and presented to EMT.
     services and major                                                                                                                                            Utilised in all development areas
     changes)                                                                                                                                                      since.

                                                                                                                                                                   Update: The organisation can now
                                                                                                                                                                   demonstrate the inclusion of patients
                                                                                                                                                                   and/or the public and the future
                                                                                                                                                                   intention to do so e.g. strategic plan
                                                                                                                                                                   engagement.

                                                                                                                                                                   October update: The organisation can
                                                                                                                                                                   now demonstrate the inclusion of
                                                                                                                                                                   patients and/or the public and the
                                                                                                                                                                   future intention to do so e.g. strategic
                                                                                                                                                                   plan engagement.


     S4BH - C17 - Non-                                            2. PPI elements to Outline                               2.1 Consultation cannot currently be   None identified
     compliant 08/09                                              and Full Business Cases                                  demonstrated through the Business case
                                                                                                                           development process - this needs to be
                                                                                                                           reinforced by the Business case review
                                                                                                                           Group. Accepted as an essential
                                                                                                                           element in all business case as
                                                                                                                           appropriate - business case templates
                                                                                                                           awaiting amendment. Members of
                                                                                                                           Business Case Review Group do not
                                                                                                                           accept cases where PPI has not been
                                                                                                                           included.
                                                                  3. Identified Independent     3.1 Action plan for work   No gaps currently identified           No gaps currently identified
                                                                  Patient Ambassadors allied to undertaken by the
                                                                  the Trust.                    Ambassadors




                                                                                                                                                                                                    8
Risk Principal Risks by Key    Risk      Actual                         Key Controls                                        Gaps
                                                  Lead Director ROYAL CORNWALL Assurances on Controls TRUST in Controls and Actions
                                                                                                HOSPITAL NHS                                                                  Gaps in Assurances and Actions
Ref          Areas           Scoring      Risk     Accountable   What controls / systems are    Where do we gain proof /  Where are we failing to put effective                   Where we are failing to gain
     What could prevent this Impact      Impact         for     in place to secure delivery of2009/10 our controls are
                                                                                                outcomes                 controls/systems in place? What action              assurance/proof that the controls are
         objective being        X          X              BOARD ASSURANCE FRAMEWORK (OCTOBER 2009) taking?
                                                  management            the objective?                 effective?                     needs                                  effective? What action needs taking?
           achieved?        Likelihood Likelihood     of risk




Overarching Objective - SAFER CARE


      Objective 3) To reduce the rates of MRSA and other healthcare associated infections through the application of best practice to
                                                provide a clean and healthy environment.

 3a    Failure to meet national    3x2      3x2      Director of   1. Trust Cleaning              1.‘Ward to Board Reporting’     1. Trust Cleaning Specification &          No gaps currently identified
       cleaning specifications      =6       =6     Estates and    Specification & protocols in   in place. Cleanliness audits    Protocols to be repackaged into a
       for cleanliness            yellow   yellow     Facilities   place to monitor the           are reported to Wards,          Cleaning Policy which is going through
                                                                   achievement of cleaning        HICC, Nursing Board & Trust     final consultation. Action: M.Pearson /
                                                                   standards across the Trust     Board.                          Q3.

       S4BH - C4a -
       Compliant
       C21 - Compliant

 3b    Failure to manage           3x3      3x2      Director of   1. Waste Management Policy     1. Ward level risk              1. The Policy must be strictly enforced      1. Weekly audits continue and provide
       waste effectively,          =9        =6     Estates and    in place which governs the     assessments, weekly             across the Trust to ensure waste is          basis for monthly assurance reports.
       maximise recycling and     amber    yellow     Facilities   segregation, storage,          exception reporting of waste    treated appropriately at ward level prior to
       minimise quantity of                                        handling, transport and        service failures to director.   collection at site disposal points. Action:
       waste created                                               disposal of waste.             Handling, transportation and    Existing weekly audits to be developed
                                                                                                  disposal documents.             into monthly reports to a wider scope of
                                                                                                                                  service delivery.
       S4BH - C4e -                                                2. The Trust has in place      2. Contracts are monitored      No gaps currently identified               No gaps currently identified
       Compliant 08/09                                             Contracts with experienced     by relevant leads with
                                                                   waste contractors for the      reporting channels in place
                                                                   removal/disposal of waste      to director.
                                                                   from trust sites.




                                                                                                                                                                                                             9
Risk Principal Risks by Key    Risk      Actual                         Key Controls                                        Gaps
                                                  Lead Director ROYAL CORNWALL Assurances on Controls TRUST in Controls and Actions
                                                                                                HOSPITAL NHS                                                                    Gaps in Assurances and Actions
Ref          Areas           Scoring      Risk     Accountable   What controls / systems are    Where do we gain proof /  Where are we failing to put effective                     Where we are failing to gain
     What could prevent this Impact      Impact         for     in place to secure delivery of2009/10 our controls are
                                                                                                outcomes                 controls/systems in place? What action                assurance/proof that the controls are
         objective being        X          X              BOARD ASSURANCE FRAMEWORK (OCTOBER 2009) taking?
                                                  management            the objective?                 effective?                     needs                                    effective? What action needs taking?
           achieved?        Likelihood Likelihood     of risk


 3c   Failure to effectively       3x3     4x2       Director of   1. Planned Preventative           1. PPM records, Risk           1. PPM, Risk Assessed Backlog & all        1. The majority of existing assurance
      manage or maintain           =9      =8       Estates and    Maintenance (PPM) &               Assessed Backlog records,      infrastructure maintenance/management      records to date are all within a paper
      building assets /           amber   amber       Facilities   Inspection Programme, Risk        external inspection records.   protocols to be repackaged into a Estate   based system which is not easy to
      equipment leading to                                         Assessed Backlog                                                 Management Policy for clarity of           interrogate; this system is being
      service failure                                              Programme, external                                              responsibility. Action: D.Hastings / Q3.   replaced with an information system
                                                                   inspection of regulated                                                                                     which will allow more effective
                                                                   equipment.                                                                                                  interrogation of maintenance
                                                                                                                                                                               performance improving assurance
                                                                                                                                                                               reporting. The information system is
                                                                                                                                                                               in operation at SMH and WCH but not
                                                                                                                                                                               yet at RCH. An external audit of
                                                                                                                                                                               statutory compliance is in progress to
                                                                                                                                                                               validate or otherwise re existing
                                                                                                                                                                               compliance. Action: D.Hastings.


      S4BH - C21 -
      Compliant
 3d   Failure to provide a safe   5x3     4x2 = 8    Director of   1. Health and Safety, Fire and    1. Internal inspection &       1. Improvements in auditing of             Assurance reporting from Ward to
      and secure                  = 15     amber    Estates and    Security Policies in place with   auditing of performance.       Ward/Departmental performance will         Board to be improved.
      environment.                red                 Facilities   internal systems of risk          Assurance reporting to         promote performance improvement
                                                                   assessment/evaluation of          Health and Safety              transparently. Action: D.Hastings (Q3).
                                                                   performance.                      Committee.


      S4BH - c20a - non-                                           2. Security audits and incident   2. Performance reporting in    2. Security audit outcomes to be           Assurance reporting to be
      compliant 08/09                                              reporting are in place which      respect of security of staff   incorporated into Divisional reporting     incorporated into Divisional reporting
                                                                   enable monitoring of security     and property is reported at    structure. Action: David Hastings (Q3).    structure. Action: David Hastings
                                                                   performance across the Trust.     monthly security review                                                   (Q3).
                                                                                                     meetings.


                                                                   3. Existing primary controls of   3. Outcome of re-validation    3. Fire Risk Assessment audit outcomes     Assurance reporting to be
                                                                   fire risk assessments and fire    process which will be          to be incorporated into Divisional         incorporated into Divisional reporting
                                                                   protection works are being re-    reported to Quality Board      reporting structure. Action : David        structure. Action: David Hastings
                                                                   validated as approved at          (Q3).                          Hastings (Q3).                             (Q3).
                                                                   Trust board Sep 2009.




                                                                                                                                                                                                              10
Risk Principal Risks by Key    Risk      Actual                         Key Controls                                        Gaps
                                                  Lead Director ROYAL CORNWALL Assurances on Controls TRUST in Controls and Actions
                                                                                                HOSPITAL NHS                                                                           Gaps in Assurances and Actions
Ref          Areas           Scoring      Risk     Accountable   What controls / systems are    Where do we gain proof /  Where are we failing to put effective                            Where we are failing to gain
     What could prevent this Impact      Impact         for     in place to secure delivery of2009/10 our controls are
                                                                                                outcomes                 controls/systems in place? What action                       assurance/proof that the controls are
         objective being        X          X              BOARD ASSURANCE FRAMEWORK (OCTOBER 2009) taking?
                                                  management            the objective?                 effective?                     needs                                           effective? What action needs taking?
           achieved?        Likelihood Likelihood     of risk


                                                                        4. Health and Safety risk        4. Evaluation of incident       Health and Safety audit outcomes to be       Assurance reporting to be
                                                                        assessments and action plans     occurrences and reporting       incorporated into Divisional reporting       incorporated into Divisional reporting
                                                                        are completed and actioned       through Health and Safety       structure. Action: David Hasting (Q3).       structure. Action: David Hastings
                                                                        by responsible person.           Committee.                      Further enforcement of local ownership of    (Q3).
                                                                                                                                         risk is required to ensure fully effective
                                                                                                                                         system of control. Action: Andrew
                                                                                                                                         Murphy (Q3).

                                                                        5. External inspection /         5. Regulating Authorities     No gaps currently identified                   No gaps currently identified
                                                                        reviews of performance from      inspection and audit reports.
                                                                        regulating authorities.

 3e   Failure to reduce C diff   4x5   = 4x3    =           Acting      1. Infection control action plan 1. Audit of infection control   1.1 Recruitment of dedicated infection       No gaps currently identified
      rates as per target           20       12             DIPC                                         polices & infection rates       control doctor.
                                   red    Amber                                                          monitored by EMT, HICC,
                                                                                                         Trust Board.
      S4BH - C4a Compliant                                                                                                               1.2 Audit data of antibiotic prescribing     No gaps currently identified
                                                                                                                                         policy. COMPLETED.

 3f   Failure to meet local      5x5     = 5x2      =       Acting      1. Infection control action plan 1. Audit of infection control   1.1 Recruitment of dedicated infection       New advert for Microbilogist I.C.
      MRSA bacteraemia              25       10             DIPC                                         policies and infection rates    control doctor.                              Doctor going out in November.
      target                       Red      Amber                                                        monitored by EMT, HICC,         1.2 Audit of suppression therapy of
                                                                                                                                                                                      Divisions charged with auditing
                                                                                                         Trust Board.                    MRSA colonised patients.
                                                                                                                                                                                      Elective Patients in Ward areas and
                                                                                                                                         1.3 Audit of compliance with elective
      S4BH - C4a Compliant                                                                                                                                                            entering them on a centralised I.C.
                                                                                                                                         screening.
      08/09                                                                                                                                                                           Database. :aunch of MRSA
                                                                                                                                                                                      suppression "care plan" in lated
                                                                                                                                                                                      October followed by Audit in Ward.


3g    Provide evidence based 4 x 4 = 16    4x1=4        Acting Director 1. Care bundles specifically     1.1 Appropriately timed         1.1 Training packages linked to all care 1.1 Review of audit programme
      care bundles which aim    red         green        of Nursing, aimed at reducing infection         regular audit.                  bundles need to be reviewed - October    necessary - October update - Review
      to promote best                                    Midwifery &                                                                     update - Review ongoing to be completed underway to be completed 30.10.09
      practice and minimise                                 AHPs /                                                                       by 30.10.09.
      risk to patients                                   Acting DIPC


      S4BH - C5a - Non                                                                                    1.2 Monitoring of audit at
      compliant 08/09                                                                                    monthly Nursing Metrics/KPI
                                                                                                         'sign-off' meeting




 Objective 4) To make substantial progress in implementing the Integrated Governance Strategy in order to ensure safe, high-quality
                                           care and full compliance with S4BH standards
                                                                                                                                                                                                                     11
Risk Principal Risks by Key    Risk      Actual                         Key Controls                                        Gaps
                                                  Lead Director ROYAL CORNWALL Assurances on Controls TRUST in Controls and Actions
                                                                                                HOSPITAL NHS                                                               Gaps in Assurances and Actions
Ref          Areas           Scoring      Risk     Accountable   What controls / systems are    Where do we gain proof /  Where are we failing to put effective                Where we are failing to gain
     What could prevent this Impact      Impact         for     in place to secure delivery of2009/10 our controls are
                                                                                                outcomes                 controls/systems in place? What action           assurance/proof that the controls are
         objective being        X          X              BOARD ASSURANCE FRAMEWORK (OCTOBER 2009) taking?
                                                  management            the objective?                 effective?                     needs                               effective? What action needs taking?
           achieved?        Likelihood Likelihood     of risk


 4a   Corporate Records           4x3      4x1      Dir of Health 1. There is in place an agreed 1. Through the realisation of 1. Delay into 09/10 regarding compliance No gaps currently identified
      leadership sought within    = 12     =4            Info     Integrated Governance action the action plan.                of C9. Action:
      the Integrated             amber    green                   plan that will implement the
      Governance structure                                        required structure.
      (required for standard
      C9 compliance)
      S4BH - C9 - non                                                                             1.2 EMT review Integrated
      compliant 08/09                                                                             Governance action plan
                                                                                                  every two weeks.


                                                                  TO                              BE                           DELETED

 4b   Risk of failing to          4x3      4x1      Acting Med    1. Board review of progress   1. SHA Review of progress      No gaps currently identified               No gaps currently identified
      implement the               = 12     =4        Director     with committee structures and with Independent
      Integrated Governance      amber    green                   HR consequences.              Management Review.
      Strategy
      S4BH - C7a&c Non                                                                          2. Chairman's Progress         No gaps currently identified               No gaps currently identified
      Compliant 08/09                                                                           Review Committee of the
                                                                                                recommendations of the
                                                                                                Independent Management
                                                                                                Review.
 4c   Organisational Learning    4x4     4x2= 8     Acting Dir of 1.Complaints/Legal/Incidents/ 1. Planned internal audit      1. Ongoing development of the CLIP         1. Learning from incidents and
      from incidents, and        = 16    amber       Nursing /    PALS (CLIP) reports to        review.                        reports and mortality review processes     complaints. Action: Strengthen
      external reviews            red              Acting Med Dir Divisions, Mortality Review.                                 with consideration of best practice in     feedback to Divisions with identified
                                                                                                                               other organisations.                       change of practice.


      S4BH - C1a -                                                2. Action plans developed       2. Annual performance        No gaps currently identified               2. Board and EMB to review action
      Compliant 08/09                                             following external              checks & external reviews.                                              plans arising from external reviews
                                                                  reviews/reports.                                                                                        e.g. S4BH, NHSLA, ALE.

 4d   Failure to implement       4x4      4x1       Acting Med    1. Guidelines/Alerts Steering   1. Planned internal audit    1. Every Division requires an annual       1. Review of the governance reporting
      new guidance e.g.          = 16     =4         Director     Process with implementation     review, Divisional           governance plan and clinical audit plan.   processes from Divisional Quality
      NICE, NSFs leading to       red    Green                    at Divisional level             governance reporting         Action:P.Upton / Clinical Governance       Board. Action: P.Upton Dec 09.
      poor quality care                                                                           through performance          Leads.
                                                                                                  reviews and Divisional
      S4BH - C5a - Non                                                                            Quality Board.
      compliant 08/09




                                                                                                                                                                                                         12
Risk Principal Risks by Key    Risk      Actual                         Key Controls                                        Gaps
                                                  Lead Director ROYAL CORNWALL Assurances on Controls TRUST in Controls and Actions
                                                                                                HOSPITAL NHS                                                                     Gaps in Assurances and Actions
Ref          Areas           Scoring      Risk     Accountable   What controls / systems are    Where do we gain proof /  Where are we failing to put effective                      Where we are failing to gain
     What could prevent this Impact      Impact         for     in place to secure delivery of2009/10 our controls are
                                                                                                outcomes                 controls/systems in place? What action                 assurance/proof that the controls are
         objective being        X          X              BOARD ASSURANCE FRAMEWORK (OCTOBER 2009) taking?
                                                  management            the objective?                 effective?                     needs                                     effective? What action needs taking?
           achieved?        Likelihood Likelihood     of risk


 4e   Develop quality              3x3    3x1= 3     Acting Dir of    1. Governance team working 1. Governance and         1. These are new requirements. Need for              Further liaison with national bodies,
      indicators and to            =9     Green       Nursing &       with Divisions to keep them Assurance Committee, EMB the governance team to have appropriate              SHA and PCT to determine what is
      publish a Quality           amber              Therapies /      informed of the required    and Board.               focus & resources to deliver. Action:                required of RCHT. May 09 - format
      Account                                       Acting Med Dir    information.                                                                                              developed and shared with the PCT.

                                                                                                                                                                                October update - further national and
                                                                                                                                                                                SHA guidance available and being
                                                                                                                                                                                integrated into RCHT proposed
                                                                                                                                                                                Quality Account.


      S4BH - C7a&c - Non                                                                               2. Engagement in DOH         No gaps currently identified                No gaps currently identified
      Compliant 08/09                                                                                  consultation on quality
                                                                                                       accounts December 09
 4f   Risk of delivering          5x3      5x1       Acting Med       1. RCHT has joined the        1. Benchmark date for the 5 1. Board and EMB monitoring of RCHT             1. Lack of patient outcome data within
      unsafe clinical care        = 15     =5         Director /      Patient Safety First Campaign interventions that come with position. Action: Acting Director of           the organisation. Action: Introduction
                                  red     Green     Acting Director   and the SHA Patient Safety    the campaign.                Nursing.                                       of PROMS and outcome data.
      S4BH - C1a -                                    of Nursing      Improvement Programme.
      Compliant 08/09 - C1b
      non compliant 08/09


4g    Appropriate leadership      4x4     2x3=6     Acting Director   1. Structure with appropriate    1.1 From August 09           1.1 Review of current Nursing, Midwifery    1.1 Membership will change with
      ability & capacity within   = 16     yellow    of Nursing,      career progression for senior    Nursing's - Nursing,         and AHP structures necessary to provide     review of the structures. June New
      the Nursing, Midwifery      red                Midwifery &      levels of staff and associated   Midwifery Advisory Group -   the senior leadership linked closely with   structure agreed by the Board.
      & AHP workforce -                                  AHPs         governing framework.             senior governing body for    divisions - completed and implemented       Negotiation with satisfied - agreed
      linked into the                                                                                  Professions.                 August 09                                   process - implemented June 09 - .
      development of the                                                                                                                                                        New leadership posts structure to
      Divisions as 'self-                                                                                                                                                       commence 03.08.09 - completed as
      standing business                                                                                                                                                         predicted.
      units'.

      S4BH - C5b -                                                                                     1.2 Nursing, Midwifery &     None identified                             None identified
      Compliant 08/09                                                                                  AHP Board - senior
      C11a - Non compliant                                                                             operational teams for
      08/09                                                                                            Professions.
                                                                                                       1.3 From June 09 Divisional None identified                              1.3 Senior Matrons to attend all new
                                                                                                       Quality Group/Divisional                                                 divisional meetings.
                                                                                                       Development and
                                                                                                       Communication Group.




                                                                                                                                                                                                               13
     S4BH - C5b -
     Compliant 08/09
     C11a - Non compliant
Risk Principal Risks by Key    Risk      Actual                         Key Controls                                        Gaps
                                                  Lead Director ROYAL CORNWALL Assurances on Controls TRUST in Controls and Actions
                                                                                                HOSPITAL NHS                                                                   Gaps in Assurances and Actions
     08/09
Ref          Areas           Scoring      Risk     Accountable   What controls / systems are    Where do we gain proof /  Where are we failing to put effective                    Where we are failing to gain
     What could prevent this Impact      Impact         for     in place to secure delivery of2009/10 our controls are
                                                                                                outcomes                 controls/systems in place? What action               assurance/proof that the controls are
         objective being        X          X              BOARD ASSURANCE FRAMEWORK (OCTOBER 2009) taking?
                                                  management            the objective?                 effective?                     needs                                   effective? What action needs taking?
           achieved?        Likelihood Likelihood     of risk


                                                                     2. Clear and understood        2.1 Clear, robust job          2.1 Review of current Nursing, Midwifery
                                                                     expectations of staff at all   descriptions.                  &AHP structures necessary to provide the
                                                                     senior levels within the                                      senior leadership linked closely with
                                                                     Nursing, Midwifery& AHP                                       divisions. June New structure agreed by
                                                                     workforce.                                                    the Board. Negotiation with satisfied -
                                                                                                                                   agreed process - implemented June 09 -
                                                                                                                                                                            2.1 New job descriptions to be drawn
                                                                                                                                   completed June 09. New leadership posts
                                                                                                                                                                            up following the review of the Nursing
                                                                                                                                   structure to commence 03.08.09 -
                                                                                                                                                                            structure. Completed and agreed
                                                                                                                                   Completed.
                                                                                                                                                                            through AfC - Senior Matron Band 8b
                                                                                                                                                                            & Matron Band 8a

                                                                                                    2.2 KSFs at every level.       None identified                             2.2 Accompanying KSF will be
                                                                                                                                                                              completed with new post holders
                                                                                                                                                                              August 09. - Final sign-off to be
                                                                                                                                                                              achieved by 30.10.09.
                                                                                                    2.3 Yearly appraisal for all   None identified                            None identified
                                                                                                    staff
                                                                     3. Organisational Leadership                                  None identified                            None identified
                                                                     development programme.

                                                                                                                                                                              None identified
                                                                                                                                   3.1 Organisational lead progress yet to
                                                                                                                                   commence.
4h   Effective nursing       3x3=9      2x3=6      Acting Director   1. Robust nursing             1.1 SAP documentation           1.1 The current nursing documentation is   1.1 Current SAP document does not
     assessments of all       amber      yellow     of Nursing,      documentation - inclusive of                                  poorly configured and is currently being   facilitate effective use & is being
     patients                                       Midwifery &      all assessments necessary for                                 reviewed - draft mock replacement just     reviewed. Pilot of documentation
                                                        AHPs         the effective assessment of                                   printed and being consulted on by senior   underway in two separate areas as
                                                                     all patients.                                                 team. Pilot of documentation underway in   two different models to be evaluated.
                                                                                                                                   two separate areas as two different        October - two models confusing -
     S4BH - D2b - Not                                                                                                              models to be evaluated.                    reduced to one and linked to eSAP
     assessed as part of                                                                                                           October - one model chosen, linked to      documentation - ongoing pilot.
     declaration                                                                                                                   ESAP documentation and back for
                                                                                                                                   ongoing pilot.


                                                                     2. Programme of Quality        2.1 Essence of Care            2.1 The current programme does not         2.1 Current documentation does not
                                                                     Nursing Metrics.               Benchmarking.                  address all areas necessary to satisfy     allow for assessment of all areas of
                                                                                                                                   S4BH requirements - all benchmarking       care necessary to appraise for all
                                                                                                                                   documentation being revised into a new     S4BH requirements - therefore cannot
                                                                                                                                   programme of Nursing Quality Metrics       provide the Board with complete
                                                                                                                                   Nutrition and Privacy and Dignity KPIs     assurance around nursing quality - all
                                                                                                                                   developed and being monitored monthly.     benchmarking documentation being
                                                                                                                                   Personal hygiene and documentation to      revised. Nutrition and Privacy and
                                                                                                                                   follow.                                    Dignity KPIs developed and being
                                                                                                                                   August - Personal and oral hygiene                                        14
                                                                                                                                                                              monitored monthly. Personal hygiene
                                                                                                                                   added. September - Documentation           and documentation to follow. August -
     S4BH - D2b - Not
     assessed as part of
     Principal Risks by Key
Risk declaration               Risk      Actual   Lead Director ROYAL CORNWALL Assurances on Controls TRUST in Controls and Actions
                                                                        Key Controls                                            Gaps
                                                                                                 HOSPITAL NHS                                                                Gaps in Assurances and Actions
Ref           Areas          Scoring      Risk     Accountable   What controls / systems are     Where do we gain proof /     Where are we failing to put effective              Where we are failing to gain
     What could prevent this Impact      Impact         for     in place to secure delivery of2009/10 our controls are
                                                                                                outcomes                    controls/systems in place? What action          assurance/proof that the controls are
         objective being        X          X      management            the objective?                  effective?
                                                          BOARD ASSURANCE FRAMEWORK (OCTOBER current programme does not            2009) taking?
                                                                                                                                         needs                              effective? What action needs taking?
           achieved?        Likelihood Likelihood     of risk                                  2.1 Essence of Care        2.1 The                                          2.1 Current documentation does not
                                                                                               Benchmarking.              address all areas necessary to satisfy           allow for assessment of all areas of
                                                                                                                          S4BH requirements - all benchmarking             care necessary to appraise for all
                                                                                                                          documentation being revised into a new           S4BH requirements - therefore cannot
                                                                                                                          programme of Nursing Quality Metrics             provide the Board with complete
                                                                                                                          Nutrition and Privacy and Dignity KPIs           assurance around nursing quality - all
                                                                                                                          developed and being monitored monthly.           benchmarking documentation being
                                                                                                                          Personal hygiene and documentation to            revised. Nutrition and Privacy and
                                                                                                                          follow.                                          Dignity KPIs developed and being
                                                                                                                          August - Personal and oral hygiene               monitored monthly. Personal hygiene
                                                                                                                          added. September - Documentation                 and documentation to follow. August -
                                                                                                                          being designed.                                  Personal and Oral Hygiene added.
                                                                                                                                                                           September - Documentation KPI
                                                                                                                                                                           being designed.


                                                                                                     2.2 Action plans following    None identified                         None identified
                                                                                                     benchmarking

                                                                                                     2.3 Monthly KPI Audit for      None identified                        2.3 Completion of monthly audit not
                                                                                                     Privacy and Dignity, Nutrition                                        consistent - new KPI's sign off
                                                                                                     and Personal Oral Hygiene.                                            meeting commenced to address
                                                                                                                                                                           them.

                                                                                                     2.4 KPI 'sign-off' meeting    None identified                         None identified
                                                                                                     monthly.
                                                                                                     2.5 Re-benchmark 6/12 for     None identified                         None identified
                                                                                                     all.



  Objective 5) To ensure robust plans are in place for the Trust's role in responding to health emergencies, including pandemic flu.

 5a   Ensure sufficient         5x3        5x2        Director of    1. Resilience Steering group 1. Executive leads for Flu    1. Depth of planning for business          1. Auditing and assurance reporting
      Business Continuity       = 15       = 10       Estates &                                   Pandemic, emergency           continuity to be developed in Divisions.   upon business continuity planning to
      Planning is in place to   red       amber        Facilities                                 preparedness and business Action: Andrew Murphy (Q3).                    be incorporated into Divisional
      adequately respond to                                                                       continuity provide reports to                                            reporting structure. Action: David
      unplanned events.                                                                           Resilience Steering Group.                                               Hastings (Q3).


      S4BH - C24 - Non                                              2. Flu Pandemic Policy and                                     None identified                         None identified
      compliant 08/09                                               plans.
                                                                    3. Active participation in                                     None identified                         None identified
                                                                    South West Emergency
                                                                    Planning Group.
                                                                    4. Business Continuity                                         None identified                         None identified
                                                                    Planning Policy & local plans.

                                                                                                                                                                                                         15
     S4BH - C24 - Non
     Principal 08/09
Risk compliantRisks by Key     Risk      Actual   Lead Director ROYAL CORNWALL Assurances on Controls TRUST in Controls and Actions
                                                                        Key Controls                                        Gaps
                                                                                                HOSPITAL NHS                                                              Gaps in Assurances and Actions
Ref          Areas           Scoring      Risk     Accountable   What controls / systems are    Where do we gain proof /  Where are we failing to put effective               Where we are failing to gain
     What could prevent this Impact      Impact         for     in place to secure delivery of2009/10 our controls are
                                                                                                outcomes                 controls/systems in place? What action          assurance/proof that the controls are
         objective being        X          X              BOARD ASSURANCE FRAMEWORK (OCTOBER 2009) taking?
                                                  management            the objective?                 effective?                     needs                              effective? What action needs taking?
           achieved?        Likelihood Likelihood     of risk


                                                                 5. Major Incident Plan and                                    None identified                           None identified
                                                                 exercise reports.

5b   Failure to have robust   4x5 = 20   4x4 = 16     Chief      1. Trust plans to manage        Detailed planning             These are `live` documents and will be    None identified
     plans in place for         red        red       Operating   health emergencies including    documents - Winter Plan       subject to ongoing continuous review in
     clinical and business                            Officer    winter pressures and            2009/10, Pandemic Flu Plan,   the light of further information and
     processes                                                   pandemic flu. Divisional and    Health Acquired Infections    guidance
                                                                 Corporate plans for business    policies and Business
                                                                 continuity. Regular             Continuity plans. Daily
                                                                 SHA/PCT/Internal Divisional     SITREP.
                                                                 briefings

     S4BH - C24 - Non                                            2 Arrangements have been                                      None identified                           None identified
     Compliant 08/09                                             made to increase our critical
                                                                 and high dependency
                                                                 capacity for adults and
                                                                 children including investment
                                                                 in key monitoring equipment
                                                                 and medical supplies



Overarching Objective - ACHIEVING FINANCIAL HEALTH
Objective 6) To achieve financial health, through meeting all financial targets, including delivering a financial surplus of £8.3 million,
                                   and thereby securing a sustainable financial future for the Trust




                                                                                                                                                                                                       16
Risk Principal Risks by Key    Risk      Actual                         Key Controls                                        Gaps
                                                  Lead Director ROYAL CORNWALL Assurances on Controls TRUST in Controls and Actions
                                                                                                HOSPITAL NHS                                                                      Gaps in Assurances and Actions
Ref          Areas           Scoring      Risk     Accountable   What controls / systems are    Where do we gain proof /  Where are we failing to put effective                       Where we are failing to gain
     What could prevent this Impact      Impact         for     in place to secure delivery of2009/10 our controls are
                                                                                                outcomes                 controls/systems in place? What action                  assurance/proof that the controls are
         objective being        X          X              BOARD ASSURANCE FRAMEWORK (OCTOBER 2009) taking?
                                                  management            the objective?                 effective?                     needs                                      effective? What action needs taking?
           achieved?        Likelihood Likelihood     of risk


 6a   Failure to deliver           5x3     5x3     Dir of Finance 1. Robust budget setting         1. Monthly integrated           1. The Trust has a number of issues      1. Until the Trust can evidence
      financial targets in 2009-   = 15   = 15                    process for 2009-10 - detailed   performance reports to the      arising that are gaps in control:-       operating in financial balance month
      10 which is to achieve a     red    red                     budgetary control framework      Board state clearly financial                                            on month, then a gap in assurance to
      surplus of £8.3m. This                                      in place, budgetary control      performance.                    a) Agency expenditure remains high.      the Board will remain. A report to the
      will result in a WEAK                                       manual, scheme of                                                                                         Board in October 2009 to
      assessment for Use of                                       delegation, standing financial   Internal and External Audit     b) Non-PbR contracted services remain demonstrate financial recovery will be
      Resources, failure to                                       procedures and financial         reports.                        above budget and not fully reimbursed to prepared and in addition Board
      make loan repayments,                                       procedures.                                                      the Trust due to the cash deal done this Members are scheduled to meet all
      intervention and                                                                                                             year.                                    Divisions to review recovery plans in
      consequential loss of                                                                                                                                                 October 2009. Action: JT October
      confidence in Trust                                                                                                          c) Non-pay spend is escalating           2009.
      Board.                                                                                                                       significantly in excess of budget.

                                                                                                                                   d) Additional expenditure above plan will
                                                                                                                                   be required to deliver 18 weeks.

                                                                                                                                   To compensate for these controls a
                                                                                                                                   detailed qualified action plan with key and
                                                                                                                                   milestones has been developed and will
                                                                                                                                   be reported to the Board in October 2009.
                                                                                                                                   Further reports on non-pay expenditure
                                                                                                                                   will also be produced. Action JT: October
                                                                                                                                   2009.

      S4BH - C7d -                                                2. Monthly reports to Board      2. Monthly board agendas        None identified                               None identified
      declaration n/a;                                                                             and reports.
      assessed by other
      measures (ALE)
                                                                  3. Audit Committee have      3. Audit Committee                  None identified                               3. Completion of Internal Audit work
                                                                  asked for separate assurance agendas and reports and                                                           on the financial reporting systems and
                                                                  on financial performance.    minutes.                                                                          Service Improvement Programme will
                                                                                                                                                                                 provide additional assurance. (JT -
                                                                                                   Internal Audit reports.                                                       November 2009).

                                                                  4. Internal and External Audit 4. Internal and External          None identified                               4. Completion of Internal Audit work
                                                                  programme in place             Audit reports &                                                                 on the financial reporting systems and
                                                                                                 recommendations.                                                                Service Improvement Programme will
                                                                                                                                                                                 provide additional assurance. (JT -
                                                                                                                                                                                 November 2009).




                                                                                                                                                                                                               17
Risk Principal Risks by Key    Risk      Actual                         Key Controls                                        Gaps
                                                  Lead Director ROYAL CORNWALL Assurances on Controls TRUST in Controls and Actions
                                                                                                HOSPITAL NHS                                                       Gaps in Assurances and Actions
Ref          Areas           Scoring      Risk     Accountable   What controls / systems are    Where do we gain proof /  Where are we failing to put effective        Where we are failing to gain
     What could prevent this Impact      Impact         for     in place to secure delivery of2009/10 our controls are
                                                                                                outcomes                 controls/systems in place? What action   assurance/proof that the controls are
         objective being        X          X              BOARD ASSURANCE FRAMEWORK (OCTOBER 2009) taking?
                                                  management            the objective?                 effective?                     needs                       effective? What action needs taking?
           achieved?        Likelihood Likelihood     of risk


                                                                 5. Capital management group 5. Capital Management           None identified                      5. A full report will be provided to the
                                                                 in place to review capital   Group papers, minutes &                                             Board outlining proposals to manage
                                                                 expenditure & ensure overall agendas.                                                            the capital programme in 2009-10
                                                                 programme is managed within                                                                      given the additional resource via the
                                                                 resources available                                                                              Department of Health of £7.7m.
                                                                                                                                                                  (Action: JT - October 2009).


                                                                 6. Divisional performance      6. Divisional performance    None identified                      6. Until Divisions can demonstrate
                                                                 reviews in place to review     reviews and reports.                                              that they can operate routinely within
                                                                 financial performance on a                                                                       available resources a gap in
                                                                 monthly basis.                                                                                   assurance remains. The Divisional
                                                                                                                                                                  Teams will each be presenting to the
                                                                                                                                                                  Trust Board in October 2009. Action:
                                                                                                                                                                  JT October 2009.

                                                                 7. Detailed financial skills   7.1 Finance skills           None identified                                  None identified
                                                                 development strategy in        development strategy for 09-
                                                                 place.                         10.

                                                                                                7.2 Finance Skills
                                                                                                Development attendance
                                                                                                records.
                                                                 8. Revised internal control    8.1 Weekly Executive         None identified                      8. Until Divisions can demonstrate
                                                                 processes approved by the      Vacancy Review Group for                                          they can operate routinely within
                                                                 Executive Team in 2009-10 in   Divisions not operating in                                        available resources a gap in
                                                                 place.                         balance.                                                          assurance remains. The Divisional
                                                                                                                                                                  Teams will each be presenting to the
                                                                                                8.2 Monthly agency spend                                          Trust Board in October 2009. Action:
                                                                                                reports to the Board.                                             JT October 2009.

                                                                 9. Service Improvement         9. See objective 2 above.    9. See objection 2 above.            9. See objective 2 above.
                                                                 Programme.




                                                                                                                                                                                                   18
Risk Principal Risks by Key    Risk      Actual                         Key Controls                                        Gaps
                                                  Lead Director ROYAL CORNWALL Assurances on Controls TRUST in Controls and Actions
                                                                                                HOSPITAL NHS                                                                          Gaps in Assurances and Actions
Ref          Areas           Scoring      Risk     Accountable   What controls / systems are    Where do we gain proof /  Where are we failing to put effective                           Where we are failing to gain
     What could prevent this Impact      Impact         for     in place to secure delivery of2009/10 our controls are
                                                                                                outcomes                 controls/systems in place? What action                      assurance/proof that the controls are
         objective being        X          X              BOARD ASSURANCE FRAMEWORK (OCTOBER 2009) taking?
                                                  management            the objective?                 effective?                     needs                                          effective? What action needs taking?
           achieved?        Likelihood Likelihood     of risk


                                                                   10. ALE action/improvement       10. ALE Updates to the            10. A number of the action plans are           None identified
                                                                   plans. Integrated                Audit Committee.                  robust, a number require significant
                                                                   performance report to board.     ALE action plans.                 further work to develop the action plan
                                                                                                    Half Year Progress Report to      and secure effective evidence to
                                                                                                    Board.                            demonstrate compliance. These will be
                                                                                                    Integrated performance            reviewed by the Director of Finance in
                                                                                                    report to Board.                  October 2008.
                                                                                                    External Audit.
                                                                                                    Half year progress report to
                                                                                                    Board.
                                                                                                    Audit Committee detailed
                                                                                                    report September 2009.
                                                                                                    SHA Review of progress
                                                                                                    being made - September
                                                                                                    2009.

 6b   Failure to deliver        3x4 =12     3x3     Dir of Finance 1. Monthly reports to Board      1. Monthly reports to Board       1. There are a number of significant           1. Until improvements in the
      adequate improvements amber           =9                     on performance against           and Finance Committee on          actions required to improve controls at all    outcomes and performance can be
      to the public sector                 amber                   Public Sector Payment Policy.    performance against Public        levels; the actions set out in the report to   identified there remains a gap in
      payment target resulting                                     Public Sector Payment Policy     Sector Payment Policy.            Finance Committee (Mar 09) include             assurance to the Board. The action
      in the Trust being a                                         Action Plan reported to                                            improvements to the procurement                plans set out in the gaps in control
      poor payer, loss of                                          Finance Committee in March                                         process, improvements to the                   section should provide assurance but
      reputation and failure to                                    2009                                                               authorisation process and improvements         only when they translate into
      support the local                                                                                                               to the payment process. Is being               improved performance; until this is
      economy.                                                                                                                        monitored via the Board. Action: J.Teape:      demonstrated this remains an area for
      S4BH                                                                                                                            Ongoing )                                      ongoing review at Board level. Gaps
                                                                                                                                                                                     in controls being monitored by the
                                                                                                                                                                                     Board. Action: J.Teape: Ongoing.
      S4BH - C7d -
      declaration n/a;
      assessed by other
      measures (ALE)

 6c   Failure to fully        4x3      =   4x2 =8   Dir of Finance 1. HRG4 Implementation           1.1 Through full & accurate       1. There are several areas of HRG4             Until final HRG4 data is completed
      implement HRG4            12          amber                  Project Team is fully in place   data recording & clinical         where the infrastructure (Reception,           and compared to HRG 3.5 then full
                               amber                               and managing all aspects of      coding on all relevant clinical   Ward Clerks) is not fully in place. Action:    assurance cannot be provided. Final
                                                                   the implementation.              activity.                         JT October 2009.                               HRG4 data to be completed October
                                                                                                                                                                                     2009. Action: JT
                                                                                                    1.2 Audit Commission
                                                                                                    reports on coding




                                                                                                                                                                                                                   19
Risk Principal Risks by Key 4x3
 6c                                               Dir of Finance
                               Risk = 4x2 =8 Lead Director ROYAL CORNWALL Assurances on Controls TRUST in Controls and Actions
                                         Actual                          Key Controls                                        Gaps                                    Gaps in Assurances and Actions
                                12       amber                                                   HOSPITAL NHS
Ref          Areas           Scoring      Risk     Accountable    What controls / systems are    Where do we gain proof /  Where are we failing to put effective         Where we are failing to gain
                              amber
     What could prevent this Impact      Impact          for     in place to secure delivery of2009/10 our controls are
                                                                                                 outcomes                 controls/systems in place? What action    assurance/proof that the controls are
         objective being        X          X               BOARD ASSURANCE FRAMEWORK (OCTOBER 2009) taking?
                                                  management             the objective?                 effective?                     needs                        effective? What action needs taking?
           achieved?        Likelihood Likelihood     of risk


     S4BH - C7d -                                                     2. Consistent and appropriate 2. See above          2.1. Outcome forms not due to be fully in As above.
     declaration n/a;                                                 processes in place for patient                      place until October 2009.
     assessed by other                                                administration; redesigned
     measures (ALE)                                                   outcome forms fully
                                                                      implemented.



                                                                      3. A number of discrete areas 3. See above          3.1 Escalation is correctly occurring  As above.
                                                                      of the Trust not progressing                        through the HRG Implementation Project
                                                                      HRG4 coding (I.e. Diagnostic
                                                                      Imaging (mapping CRIS to
                                                                      CACI; GUM needs a SUS
                                                                      feed; Neonatal HDU needs
                                                                      CACI feed)

                                                                      4. Awareness programme is 4. See above              No gaps currently identified.             No gaps currently identified.
                                                                      being systematically rolled out
                                                                      through the Trust.

6d   Failure to realise the     4 x 4 = 16 4 x 4 = 16   Director of   1. Board focus on the        1. Board Reports.      1. The operating capacity of the unit is     1. Development of new business and
     potential of the Cornwall     red        red        Finance      financial and operational                           only 18% utilised resulting in a significant management capacity and capability.
     Food Production Unit                                             performance of the Unit.                            financial drain on the Trust's resources.
     resulting in a significant                                                                                                                                        KPMG have been appointed to advise
     annual financial loss to                                                                                                                                          on governance and management
     the Trust, failure to                                                                                                                                             options. Action: J Teape - October
     achieve financial targets                                                                                                                                         2009.
     and consequential loss
     of confidence in Trust
     Board




                                                                                                                          2. Experienced commercial management None identified
                                                                                                                          capacity does not exist.


Overarching Objective - STRATEGIC PLANNING AND RELATIONSHIPS




                                                                                                                                                                                                    20
Risk Principal Risks by Key    Risk      Actual                         Key Controls                                        Gaps
                                                  Lead Director ROYAL CORNWALL Assurances on Controls TRUST in Controls and Actions
                                                                                                HOSPITAL NHS                                                                     Gaps in Assurances and Actions
Ref          Areas           Scoring      Risk     Accountable   What controls / systems are    Where do we gain proof /  Where are we failing to put effective                      Where we are failing to gain
     What could prevent this Impact      Impact         for     in place to secure delivery of2009/10 our controls are
                                                                                                outcomes                 controls/systems in place? What action                 assurance/proof that the controls are
         objective being        X          X              BOARD ASSURANCE FRAMEWORK (OCTOBER 2009) taking?
                                                  management            the objective?                 effective?                     needs                                     effective? What action needs taking?
           achieved?        Likelihood Likelihood     of risk



       Objective 7) To develop a medium-term plan for the Trust's future development which will identify clinical strengths and key
       priorities. It is likely that there will be a number of different dimensions to this plan including a clinical strategy, a teaching,
     education and research strategy, a consideration of the Trust's position in the local economy; including its environmental impact
                                  and the estate, infrastructure and investment to deliver these strategic goals.
 7a    Failure to implement          5x2       3x2        Director of   1. Trust Estate Strategy      1. Development Control        1.1 Development of Clinical Strategy        1. Enhanced outcome reporting to
       appropriate Estate            = 10       =6       Estates and                                  Plans and other supporting    required to allow further detailing of      Board. Action: D.Hastings
       Strategy                     amber     yellow       Facilities                                 documents to the Strategy     Estates Plans. Action: P.Upton

       S4BH - C20a - Non                                                                                                            1.2 Further development of KPI's to allow
       Compliant 08/09                                                                                                              effective monitoring of Estate Strategy
                                                                                                                                    outcomes required. Action: D.Hastings

7b     Absence of clinical         4x5 = 20   4x2 = 8   Acting Medical 1. Development of a clinical   1. Board approval of the      1. Consultation on the developing clinical No gaps currently identified
       strategy inhibits service     red       amber       Director    strategy as the key            draft RCHT Strategic Plan,    strategy with the wider clinical community
       planning and                                                    component of the RCHT          22 Oct 09.                    and RCHT partners. Action: Board
       development                                                     Strategy.
       S4BH - C7a&c - Non                                              2. Public consultation on Draft
       Compliant 08/09                                                 Strategic Plan Nov & Dec
                                                                       2009
7c     Absence of teaching,          4x3      4x1 = 4   Acting Medical 1. Development of these         1. Board approval of the     1. Consultation with key partners.          No gaps currently identified
       education and research        = 12     Green        Director    strategies as part of the       draft RCHT Strategic Plan,
       strategy results in          amber                              RCHT Draft Strategic Plan       Oct 09.
       RCHT missing
       developmental
       opportunities


7d     Non-achievement of      5 x 3 = 15 5 x 3 = 15      Director of   1. Programme and scheme       1. Validation of programmes Project Board and Project Terms of            End user requirements have yet to be
       clinical strategic site    red        red         Estates and    estimates for individual      and schemes estimates as Reference not yet agreed. Action: Project        validated. Action Executive Team Q3
       development plan to                                 Facilities   projects.                     individual requirements are Board to agree PID - Q3
       meet user requirements                                                                         developed.                                                            Project Board reporting needs to be
       to appropriate cost and                                                                                                    Clinical Leadership resources to be       established to assure programme,
       programme with no                                                                                                          allocated. Action COO Q3                  costs and avoidance of service
       adverse impacts on                                                                                                                                                   delivery impact. Action Executive
       service delivery.                                                                                                            Estates project management resources to Team Q3
                                                                                                                                    be allocated. Action DoEF Q3


     Objective 8) To strengthen working relationships with other health and social care organisations in Cornwall in order to improve
                                                            patient outcomes
                                                                                                                                                                                                               21
Risk Principal Risks by Key    Risk      Actual                         Key Controls                                        Gaps
                                                  Lead Director ROYAL CORNWALL Assurances on Controls TRUST in Controls and Actions
                                                                                                HOSPITAL NHS                                                                       Gaps in Assurances and Actions
Ref          Areas           Scoring      Risk     Accountable   What controls / systems are    Where do we gain proof /  Where are we failing to put effective                        Where we are failing to gain
     What could prevent this Impact      Impact         for     in place to secure delivery of2009/10 our controls are
                                                                                                outcomes                 controls/systems in place? What action                   assurance/proof that the controls are
         objective being        X          X              BOARD ASSURANCE FRAMEWORK (OCTOBER 2009) taking?
                                                  management            the objective?                 effective?                     needs                                       effective? What action needs taking?
           achieved?        Likelihood Likelihood     of risk


8a    Failure to strenghen      5 x 3 = 15 5 x 1 = 5       Chief      1. Joint strategy meetings.   1. Joint strategy meetings.   None identified                                 None identified
      relationships with health    red      yellow       Executive
      and social care partners                                        2. Chairmans Progress         2. Chairmans Progress
      in the community.                                               Committee.                    Committee.

                                                                      3. Getting Patients Treated   3. Getting Patients Treated
                                                                      Group                         Group




Overarching Objective - DEVELOPING THE INFRASTRUCTURE

      Objective 9) To strengthen information systems and analysis in the Trust to support service transformation, including moving
                               towards understanding individual patient costs, outcomes and experiences.
 9a   Failure of Trust to          4x3       4x3       Dir of Finance 1. Patient Level Costing      1.1 Patient Level Costing     Whilst the project is well managed and          At present the Trust is unable to
      adequately understand        = 12      = 12                     Project Board                 Project Board agendas and     has dedicated project management                identify reliable patient level data and
      the costs of individual     amber     amber                                                   minutes.                      resource it has not yet been possible to        therefore a gap in assurance to the
      patients, services, and                                                                                                     produce a first cut of Trust data due to        Board is evidence. Action - J Teape -
      the income generated,                                                                         1.2 PID                       technical difficulties, work is ongoing to      December 2009.
      resulting in an inability                                                                                                   rectify this, until this is addressed gaps in
      to manage service lines                                                                       1.3 Project Plans and         control exist. Action J Teape - December
      effectively, increasing                                                                       Timetable                     2009.
      the possibility of not
      delivering financial
      targets & taking sound
      decisions based on high
      quality financial
      information. Further risk
      that income will not
      appropriately collected




      S4BH - C7d -
      declaration n/a;
      assessed by other
      measures (ALE)




                                                                                                                                                                                                                  22
Risk Principal Risks by Key    Risk      Actual                         Key Controls                                        Gaps
                                                  Lead Director ROYAL CORNWALL Assurances on Controls TRUST in Controls and Actions
                                                                                                HOSPITAL NHS                                                                 Gaps in Assurances and Actions
Ref          Areas           Scoring      Risk     Accountable   What controls / systems are    Where do we gain proof /  Where are we failing to put effective                  Where we are failing to gain
     What could prevent this Impact      Impact         for     in place to secure delivery of2009/10 our controls are
                                                                                                outcomes                 controls/systems in place? What action             assurance/proof that the controls are
         objective being        X          X              BOARD ASSURANCE FRAMEWORK (OCTOBER 2009) taking?
                                                  management            the objective?                 effective?                     needs                                 effective? What action needs taking?
           achieved?        Likelihood Likelihood     of risk


9b    Informatics capabilities     4x3       4x2      Dir of Health 1. Information Business Case 1. Informatics Programmes       1. Information Business Case not yet       1. Escalation route yet to be agreed
      and capacity not             = 12      =8            info     presented & supported at     fully completed (particularly   approved. Action: R.Johnson                from these Informatics Boards Action:
      developed throughout        amber     amber                   leadership                   Service Line Reporting                                                     R.Johnson / M.Haynes
      the Trust                                                                                  project)


      S4BH - D6 - not
      included in                                                    TO                              BE                          DELETED
      declaration
 9c   System infrastructure    4x3    =     4x2 = 8   Dir of Health 1. Appropriate allocation of   1.1 Service Line Reporting    No gaps currently identified               No gaps currently identified
      not developed to             12        amber         info     capital monies to deliver      project on target
      required level to support amber                               required system infrastructure
      Patient Level Costing


      S4BH - C7b - Non
      compliant 08/09                                                TO                              BE                          DELETED

9d    Failure to get             5x4    =   5x2 =     Acting Medical 1. Divisional management        1. Board reports.           1. Need for development of the divisional Improved learning from incidents and
      appropriate information     20 Red     10          Director    teams and information                                       management structures.                    complaints.
      flow from Board to                    Amber                    dissemination through them
      Ward, and Ward to
      Board
      S4BH - C7a&c - Non                                             2. Patient Safety Campaigns. 2. Staff survey.               None identified                            None identified
      compliant 08/09




   Objective 10. To ensure the Trust meets the pledges to staff in the NHS constitution around quality work, safety and wellbeing,
learning and development and involvement and partnership, thus improving staff satisfaction and supporting staff in delivering high
                                                          quality services.
10a Lack of capacity within        4x3      4x2 =      Director of   1. Draft revised HR             1. LDP Business Planning    1.Monitoring the effectiveness of the new Initial draft structure developed. JDs
    the HR Structure               = 12        8        Human        Directorate Structure to        process;                    structure once implemented. Action: JP    being processed to articulate detail of
                                  amber      amber     Resources     ensure it is fit for purpose,                                                                         the role. Upon completion roles to be
                                                                     and aligned with Divisional &                                                                         matched & evaluated under agenda
                                                                     Delivery                                                                                              for change.




                                                                                                                                                                                                           23
Risk Principal Risks by Key    Risk      Actual                         Key Controls                                        Gaps
                                                  Lead Director ROYAL CORNWALL Assurances on Controls TRUST in Controls and Actions
                                                                                                HOSPITAL NHS                                                               Gaps in Assurances and Actions
Ref          Areas           Scoring      Risk     Accountable   What controls / systems are    Where do we gain proof /  Where are we failing to put effective                Where we are failing to gain
10a                            4x3     4x2 =        Director of
     What could prevent this Impact      Impact         for     in place to secure delivery of2009/10 our controls are
                                                                                                outcomes                 controls/systems in place? What action           assurance/proof that the controls are
                               = 12         8        Human
         objective being        X          X              BOARD ASSURANCE FRAMEWORK (OCTOBER 2009) taking?
                                                  management            the objective?                 effective?                     needs                               effective? What action needs taking?
                              amber      amber      Resources
           achieved?        Likelihood Likelihood     of risk


     S4BH - C11a - Non                                            2. Successful Business           2. Agreed additional      2. Pending consultation within the HR        Internal acting arrangements agreed
     compliant 08/09                                              Planning outcome to achieve      Resources required via    Structure and Business Partners, delay in    pending HR directorate restructure.
     Joint Independent                                            additional financial resources   External Jointly          recruitment to vacant posts. Action: JP      Interim appointments being
     Review Report Para                                           internally through OD budget     Commissioned Review; the                                               considered to fill gaps with particular
     [68]                                                         to support additional            RCT Trust Board annual HR                                              focus on Equality and Diversity. HR
                                                                  infrastructure posts;            report 2008; Strategic                                                 support to divisions under the
                                                                                                   Resources Committee,                                                   business partner model.
                                                                                                   2008.
                                                                  3. Securing 1 year fixed-term 3. Business Plan submitted      3. Pending new posts being AFC banded; Jobs have been AFC matched, posts
                                                                  funding from SHA to support and accepted by SHA,              Finalisation of internal consultation with being advertised to recruit into the
                                                                  Workforce Development         March 2009.                     Business Partners.                         new posts to support workforce
                                                                                                                                                                           development.
10b Failure to achieve &       4x3      4x2 =       Director of   1. Standard Leads in place       1. Regular Top Team Leads No gaps currently identified                 No gaps currently identified
    deliver Corporate          = 12        8         Human                                         meetings with Director of HR
    Compliance within         amber      amber      Resources
    Human Resources
    [S4BH]
     S4BH - 2008-09 C7e -                                         2. Action & Development          2. Reviewed at TT meetings; No gaps currently identified               No Gaps currently identified
     Compliant                                                    Plans for 09/10 all standards
     C8a - Compliant                                              update monthly.
     C8b - Non compliant                                          3. Monitor & Review              Top team & EMT action        No Gaps currently identified              No gaps currently identified
     C10a - Compliant                                             standards via Directorate TT     plans; EMT assurance
     C10b - Compliant                                             Meetings; improved rigour &      meetings; Board scrutiny &
     C11a -Non Compliant                                          review / assessment at EMB       involvement of assurance
     C11b - Compliant                                             level.                           process
     C11c - Compliant




10c Failure to achieve         4x3      4x2 =       Director of   1. Appraisal Policy              1. Evidence raised at        1. Absence of new Divisional              No Gaps currently identified
    Standards for Better       = 12        8         Human                                         Divisional Performance       Performance review arrangements.
    Health ref. 8b, non       amber      amber      Resources                                      Reviews of Appraisal and
    completion of review of                                                                        PDP trajectories
    appraisal
    documentation
     S4BH - C8b - Non
     compliant 08/09




                                                                                                                                                                                                          24
10c                            4x3     4x2 =        Director of
                               = 12         8        Human
Risk Principal Risks by Key amber
                               Risk      amber
                                         Actual     Resources           Key Controls                                        Gaps
                                                  Lead Director ROYAL CORNWALL Assurances on Controls TRUST in Controls and Actions                                    Gaps in Assurances and Actions
                                                                                                HOSPITAL NHS
Ref          Areas           Scoring      Risk     Accountable   What controls / systems are    Where do we gain proof /  Where are we failing to put effective            Where we are failing to gain
     What could prevent this Impact      Impact         for     in place to secure delivery of2009/10 our controls are
                                                                                                outcomes                 controls/systems in place? What action       assurance/proof that the controls are
         objective being        X          X              BOARD ASSURANCE FRAMEWORK (OCTOBER 2009) taking?
                                                  management            the objective?                 effective?                     needs                           effective? What action needs taking?
     S4BH -achieved?
            C8b - Non       Likelihood Likelihood     of risk
     compliant 08/09

                                                                                                  2. New HR score-card for    No gaps currently identified            No gaps curently identified
                                                                                                  Performance reporting to
                                                                                                  Trust Board developed




10d Lack of adequate          5x3 = 15   5x3 = 15    Director of   CHESS service change plan      Board reports upon CHESS Project Initiation Document to be agreed   Implementation of PID to be
    capacity within the         red        red       Estates &     agreed at Board Sep 09.        Review Implementation.   by CHESS Board and Chief executives        monitored by Director of Estates and
    Estates function                                  Facilities                                                                                                      Facilities and reported to Trust Board.




              Objective 11) To minimise the environmental impact of the Trust's activities and ensure sustainable development.
11a Failure to implement       3x5       3x5 =       Director of   1. Draft Carbon Reduction      1. Implementation of Carbon 1. Carbon Reduction Strategy & Action   1. Progress reporting to Board on
    appropriate Carbon         = 15       15 red     Estates &     plan reviewed by Strategic     Reduction Initiative across Plan to be approved by Board. Action:   implementation of action plan. Action:
    Reduction Strategy         red                    Facilities   Resources Committee            Trust                       D.Hastings (Q3)                         D. Hastings
    leading to unacceptable
    medium term strategy /
    performance

      S4BH - C21 -
      Compliant

        Objective 12) To continue to strengthen management and planning processes in the Trust, developing the organisation in
                                        preparation for an application for Foundation Trust status.
12a Delivery on                5x5        5x1          CEO         1. Chairman's Progress                                     This Committee will oversee             No gaps in assurances have been
    recommendations            = 25        =5                      Committee created to oversee                               implementation of the 27 review         identified. The Chairman's Progress
    within the Independent     red       yellow                    delivery of recommendations.                               recommendations. These 27 gaps in       Committee will seek internal
    Review of Management                                           Convened 21st May.                                         control sit under 4 core themes:        assurances on progress to ensure
    and Governance at                                                                                                                                                 they are effective in identifying any
    RCHT                                                                                                                                                              gaps in implementation.

      S4BH - C7a&C - Non                                                                          1.1 ToR details membership, 1.1 Financial management &              None identified
      compliant 08/09                                                                             frequency, and Committee's performance
      C7b - Non compliant                                                                         2 prime objectives
      08/09

                                                                                                  1.2 Committee action plan   1.2 Strategy and business planning      None identified
                                                                                                  provides assurances of
                                                                                                  progress against assigned
                                                                                                  leads
                                                                                                                                                                                                     25
     S4BH - C7a&C - Non
     compliant 08/09
     Principal compliant
Risk C7b - NonRisks by Key     Risk      Actual   Lead Director ROYAL CORNWALL Assurances on Controls TRUST in Controls and Actions
                                                                        Key Controls                                        Gaps
                                                                                                HOSPITAL NHS                                                            Gaps in Assurances and Actions
Ref 08/09 Areas              Scoring      Risk     Accountable   What controls / systems are    Where do we gain proof /  Where are we failing to put effective             Where we are failing to gain
     What could prevent this Impact      Impact         for     in place to secure delivery of2009/10 our controls are
                                                                                                outcomes                 controls/systems in place? What action        assurance/proof that the controls are
         objective being        X          X              BOARD ASSURANCE FRAMEWORK (OCTOBER 2009) taking?
                                                  management            the objective?                 effective?                     needs                            effective? What action needs taking?
           achieved?        Likelihood Likelihood     of risk


                                                                                                                              1.3 Trust management & leadership        None identified
                                                                                                                              1.4 Trust, PCT & SHA relationships       None identified
                                                                                                                              JUNE ACTION UPDATE: Progress
                                                                                                                              moving in line with expectations
                                                                  2. Action Plan agreed &                                     None identified                          None identified
                                                                  progress reported
12b Compliance with          4 x 3 = 12   3x2=6     Acting Director 1. Monthly reviews by all    1. Updated action plans      3.New report to be included in agenda for 1. Updated action plans not being
    Standards For Better       amber       yellow    of Nursing, responsible Execs and their     stored on S4Bh shared        July Board meeting as part of Integrated stored on the shared drive -
    Health is supported by                           Midwifery & standard leads.                 drive.                       Performance Report.                       September improved considerably all
    a robust internal                                    AHPs                                                                                                           now there if necessary.
    assurance process

     S4BH - c7a&c non-                                            2. Monthly report/update to    2. EMB minutes.              None identified                          None identified
     compliant 08/09                                              EMB.

                                                                  3. Monthly inclusion of         3. Board minutes.           None identified                          3. New assurance first set of minutes
                                                                  position statement in                                                                                as evidence will be end of July 09.
                                                                  Executive Board Report.

                                                                    4. Named co-ordinator to      4. Regular report/updated   None identified                          4. July-September Board update as
                                                                  lead and control process.      compliance RAG to named                                               part of minutes.
                                                                                                 responsible Exec. Director

                                                                  5. June - Detailed self-       5. Self-assessments on       None identified                          5. No formal feedback from PCT.
                                                                  assessment for all standards   shared drive and shared with
                                                                  compiled and monitored         PCT.
                                                                  monthly.
                                                                  6. NED scrutiny of selected    6. S4BH NED scrutiny        None identified                           None identified
                                                                  standards.                     scheduled for October Board
                                                                                                 seminar and October
                                                                                                 governance and Assurance
                                                                                                 Committee.




                                                                                                                                                                                                     26
Risk Reg Principle Risks   Risk      Residue   Lead Director     Key Controls
         by Key Areas      Scoring   Risk      Director          What controls / systems
         What could                            accountable for   we have in place to
         prevent this                          management of     assist in securing
         objective being                       risk              delivery of our objective
         achieved
Assurances on Controls        Gaps in Controls      Action          Gaps in                 Action
Where we can gain             Where are we          What action     Assurances              What action we
evidence that our controls’   failing to put        we are          Where we are failing    are taking to the
systems, on which we are      controls/systems in   taking to the   to gain evidence that   address the gap
placing reliance, are         place and/or where    address the     our controls systems,   in assurance
effective                     we are failing in     gap in          on which we place
                              making them           control         reliance, are
                              effective                             effective

				
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