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Objective 1

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									             Enclosure Oi                                                                                                                                                                                                                                                                                                             Objective 1

                                                                                                                                                                                Board Assurance Framework 2009-2010




         Principle Objective 1:                                            The Trust will continue to implement systems that support zero tolerance of all Hospital Acquired Infections (HAI)

         SfBH Domain                                                       Safety, Care Environment & Amenities

         Lead Director                                                     Medical Director

Major Element                                                                                                                                                                                                                                        Lead
                                                                                                                                                                                                                                                                                                                                            Deadline
         Improve perfomance against the Department of Health Care Bundles, relating to HAI, by the introduction of clear measurement,
1.1                                                                                                                                                                                                                                                  Medical Director                                                                       3/31/2010
         reporting and on-going monitoring processes
                                                     Current
                                                     Totals
ID       Risks                  Initial Risk                          Controls               Assurances         Reported Assurances                                                                               Current Risk Gaps in Controls                                 Gaps in Assurance        Action Plan              Who         When
                                  Rating                                                                         Identified in Board Reports                                                                      Rating JUN
                                                                           Intial (Inherent)




                                                                                                                                                                                       and External Assessments
                                        Consequence




                                                                                                                                                                                                                  Consequence
                                                      Likelihood




                                                                                                                                                                                                                                Likelihood
                                                                                                                   MARCH
                                                                                               JUNE
                                                                                                      SEPT
                                                                                                             DEC
                                                                   Total




                                                                                                                                                                                                                                             Total
     382 Poor compliance with the        4            3            12      12 12                      0      0      0 Saving Lives Audits                 Infection Prevention Board                               4             3           12 Process for cluster of                              Patient Safety Team to Associate            Ongoing
         HCAI Care Bundles due to                                                                                                                         Meetings                                                                                   HCAIs (non-MRSA/C.Diff)                        identify workstream lead Director for
         lack of clinical engagement                                                                                       Infection Prevention Board     Patient Safety Meetings                                                                                                                   and priorities for       Nursing
                                                                                                                           Root Cause Analysis (RCA)      Clinical Governance                                                                        Patients with Community                        Implement care bundle    Head of            Ongoing
                                                                                                                           Global Trigger Tool            Committee                                                                                  Acquired Pneumonias not                        for community acquired   Governance
                                                                                                                                                                                                                                                                                                    pneumonias
                                                                                                                           Compliance to the Health Act




     383 Lessons learnt are not          4            4            16                          16     0      0      0 Learning Log                        Infection Prevention Board                               4             4           16 Clinical attendance at                              General Managers to      Associate        31/07/2009
         embedded due to the lack                                                                                          HCAI Action Plan               Meetings
                                                                                                                                                          Patient Safety Meetings                                                                    RCA meetings                                   arrange RCA meetings     Director for
         of ownership by the clinical                                                                                                                                                                                                                                                               and ensure               Nursing
                                                                                                                           Compliance to the Health Act   Clinical Governance                                                                        Dissemination of Lessons
         divisions                                                                                                                                                                                                                                                                                  implemntation of any
                                                                                                                           Root Cause Analysis (RCA)      Committee                                                                                  learnt
                                                                                                                                                                                                                                                                                                    actions identified




                                                                                                                                                                                       Collated by Pat Morris
                                                                                                                                                                                       Head of Governance                                                                                                                                               1
             Enclosure Oi                                                                                                                                                                                                                                                                                                                 Objective 1

                                                                                                                                                                            Board Assurance Framework 2009-2010




Major Element                                                                                                                                                                                                                                          Lead
                                                                                                                                                                                                                                                                                                                                             Deadline

1.2      Demonstrate compliance with the MRSA Screening for designated elective specialties                                                                                                                                                            Medical Director                                                                      On-going

                                                                                                      Current
                                                                                                      Totals
ID       Risks                           Initial Risk                                                                             Controls                     Assurances             Reported Assurances           Current Risk Gaps in Controls                         Gaps in Assurance               Action Plan              Who         When
                                           Rating                                                                                                                                     Identified in Board Reports   Rating JUN
                                                                         Intial (Inherent)
                                                                                                                                                                                      and External Assessments
                                      Consequence




                                                                                                                                                                                                                    Consequence
                                                    Likelihood




                                                                                                                                                                                                                                  Likelihood
                                                                                                                 MARCH
                                                                                             JUNE
                                                                                                    SEPT
                                                                                                           DEC
                                                                 Total




                                                                                                                                                                                                                                               Total
     384 Fail to meet 100% elective    2            3            6           6               6      0      0      0 Elective MRSA Screening              Infection Prevention Board                                  2             3           6                          No process for monitoring Discuss with Assoc         Medical         31/07/2009
         case screening target                                                                                           Procedure in place and active                                                                                                                    compliance                Director of Information    Director
                                                                                                                                                         Trust Board                                                                                                                                method for comparing
                                                                                                                         Dedicated resources in POAC                                                                                                                                                decisions to admit with
                                                                                                                         for screening of surgical                                                                                                                                                  lab screening results
                                                                                                                         admissions

                                                                                                                         MRSA Patient Information                                                                                                                                                    Put in place a process to Medical         31/07/2009
                                                                                                                         Leaflets                                                                                                                                                                    enable perfromance        Director
                                                                                                                                                                                                                                                                                                     against the target to be
                                                                                                                                                                                                                                                                                                     measured



Major Element                                                                                                                                                                                                                                          Lead
                                                                                                                                                                                                                                                                                                                                             Deadline

1.3      Develop a plan for implementing MRSA Screening for non-elective patients - no risks identified                                                                                                                                                Medical Director                                                                      12/31/2009




                                                                                                                                                                                      Collated by Pat Morris
                                                                                                                                                                                      Head of Governance                                                                                                                                                2
              Enclosure Oi                                                                                                                                                                                                                                                                                                                Objective 1

                                                                                                                                                                               Board Assurance Framework 2009-2010




Major Element                                                                                                                                                                                                                                            Lead
                                                                                                                                                                                                                                                                                                                                                 Deadline

1.4       Review the Trust's policy on use of isolation facilities and side-rooms                                                                                                                                                                        Director of Operations & Nursing                                                          12/31/2009

                                                                                                       Current
                                                                                                       Totals
ID        Risks                           Initial Risk                                                                             Controls                    Assurances               Reported Assurances           Current Risk Gaps in Controls                                   Gaps in Assurance       Action Plan              Who         When
                                            Rating                                                                                                                                      Identified in Board Reports   Rating JUN
                                                                          Intial (Inherent)
                                                                                                                                                                                        and External Assessments
                                       Consequence




                                                                                                                                                                                                                      Consequence
                                                     Likelihood




                                                                                                                                                                                                                                    Likelihood
                                                                                                                  MARCH
                                                                                              JUNE
                                                                                                     SEPT
                                                                                                            DEC
                                                                  Total




                                                                                                                                                                                                                                                 Total
     386 Siderooms not being            4            4            16      16 12                      0      0      0 Bed Management Policy               Monitor time to isolate                                       4             3           12 New Build                                             Implement new building   Director of     31/10/2009
         available insufficient                                                                                                                          performance                                                                                                                                      project                  Development
         numbers to meet isolation
                                                                                                                          Agreed Business Case to        Outbreak meetings                                                                               Infection Prevention                             Guideline to Infection   Infection       31/10/2009
         needs
                                                                                                                          increase bed capacity by 26 in                                                                                                 Guideline for use of side-                       Prevention Board then    Prevention
                                                                                                                          total and reprovide two wards Infection Control Reports to                                                                     rooms (predominately for                         Management Board for     Matron
                                                                                                                          with 50% siderooms             Infection Prevention                                                                            new build)                                       approval
                                                                                                                                                         Board/Clinical Governance
                                                                                                                          Cohort/Isolate patients on     Committee/Trust Board                                                                           Bed Management Policy                            Bed management          GM for           30/06/2009
                                                                                                                          Squire with HAI                                                                                                                out-of date                                      procedure and           Medicine
                                                                                                                                                                                                                                                                                                          guidelines reviewed and
                                                                                                                                                                                                                                                                                                          updated to Management
                                                                                                                                                                                                                                                                                                          Board for approval


Major Element                                                                                                                                                                                                                                            Lead
                                                                                                                                                                                                                                                                                                                                                 Deadline

1.5       Ensure all relevant staff have received Hand Hygiene Training                                                                                                                                                                                  Medical Director                                                                        On-going

                                                                                                       Current
                                                                                                       Totals
                                                                                                                  MARCH
                                                                          Intial (Inherent)
                                                                                              JUNE
                                                                                                     SEPT
                                                                                                            DEC




ID        Risks                           Initial Risk                                                                             Controls                    Assurances               Reported Assurances           Current Risk Gaps in Controls                                   Gaps in Assurance       Action Plan              Who         When
                                            Rating                                                                                                                                      Identified in Board Reports   Rating JUN
                                                                                                                                                                                        and External Assessments
                                       Consequence




                                                                                                                                                                                                                      Consequence
                                                     Likelihood




                                                                                                                                                                                                                                    Likelihood
                                                                  Total




                                                                                                                                                                                                                                                 Total
     234 Failure to follow Infection    5            3            15      15 10                      0      0      0 Training programme                  Attendance register           Monthly hand hygiene audits     5             2           10
         Prevention Policies &                                                                                                                                                         presented at Infection
         Procedures                                                                                                                                                                    Prevention Board
                                                                                                                          Zero tolerance statement       Infection Prevention Board
                                                                                                                                                         monthly minutes
                                                                                                                          Annual Mandatory training      Trust Board reports
                                                                                                                          Induction programme for new    Hand hygiene audits
                                                                                                                          trainee doctors x 3 pa
                                                                                                                          Induction programme for new
                                                                                                                          starters
                                                                                                                          Trained link staff at
                                                                                                                          departmental level
                                                                                                                          Ward managers attend IPB to
                                                                                                                          present hand hygiene audits




                                                                                                                                                                                         Collated by Pat Morris
                                                                                                                                                                                         Head of Governance                                                                                                                                                 3
             Enclosure Oi                                                                                                                                                                                                                                                                                      Objective 1

                                                                                                                                                                             Board Assurance Framework 2009-2010




Risks carried forward from BAF 2008/9 relevant to Priniciple Objective 1                                                                                                                                                                                 Medical Director                                           On-going
                                                                                                     Current
                                                                                                     Totals
ID       Risks                          Initial Risk                                                                              Controls                     Assurances               Reported Assurances           Current Risk Gaps in Controls                         Gaps in Assurance   Action Plan   Who     When
                                          Rating                                                                                                                                        Identified in Board Reports   Rating JUN


                                                                        Intial (Inherent)
                                                                                                                                                                                        and External Assessments
                                     Consequence




                                                                                                                                                                                                                      Consequence
                                                   Likelihood




                                                                                                                                                                                                                                    Likelihood
                                                                                                                MARCH
                                                                                            JUNE
                                                                                                   SEPT
                                                                                                          DEC
                                                                Total




                                                                                                                                                                                                                                                 Total
     261 Cleanliness of the           5            3            15      15 10                      0      0      0 Increased resources dedicated Audits of cleaning                    Infection Prevention Board      5             2           10
         environment and                                                                                                to cleaning and disinfection     environment
         equipment does not meet
         the required standards to                                                                                      Sterinis Hydrogen peroxide       Weekly report from Hotel      Clinical Governance
         prevent the spread of                                                                                          generators                       Services Manager to           Committee (14/05)
         infection                                                                                                                                       Executive Team
                                                                                                                        Deep Cleaning Rota for Clinical Monitoring by Hotel            Results of Peat Report
                                                                                                                        Areas                           Services and Infection         Reported to Clinical
                                                                                                                        Terminal cleaning team in       Prevention Team                Governance Committee
                                                                                                                        place                                                          (14/05/2009)
                                                                                                                        Ward and department              Key Performance Indicators
                                                                                                                        managers given responsibility    for ISS Mediclean: Report
                                                                                                                        for management of cleanliness    from Hotel Services to Ward
                                                                                                                        standards, including             Managers: Exception report
                                                                                                                        equipment, in their own          to AGMs
                                                                                                                        environment

                                                                                                                        Trust fully complies with 2007   Provided through on-going
                                                                                                                        Cleaning Guidelines              monitoring against agreed
                                                                                                                        Weekly/monthly/quarterly         contract specification
                                                                                                                        managerial inspections of        reported to Management
                                                                                                                        clinical areas carried out by    Board
                                                                                                                        Hotel Services
                                                                                                                        Quarterly inspections of clinical Cleanliness audits adhere
                                                                                                                        areas by Patient Forum Team to Government Guidelines

                                                                                                                        Roles and responsibilites of     Audit of inspected areas,
                                                                                                                        managers reinforced by the       action plan produced for
                                                                                                                        Infection Prevention and         areas of concern, Hotel
                                                                                                                        Control Matron                   Services monitor actionplan
                                                                                                                                                         to ensure completion.
                                                                                                                        Positioning of Hand Gel          Reported through Patient
                                                                                                                        dispensers reviewed by           Experience Group
                                                                                                                        Infection Control Team

                                                                                                                        Hand Hygiene Information         Patient Forum Audit on
                                                                                                                        Signs made more visible          Handwashing

                                                                                                                        Cleaning Strategy 2009           Annual PEAT Report




                                                                                                                                                                                         Collated by Pat Morris
                                                                                                                                                                                         Head of Governance                                                                                                                    4
             Enclosure Oi                                                                                                                                                                                                                                                                      Objective 1

                                                                                                                                                                                  Board Assurance Framework 2009-2010




                                                                                                       Current
                                                                                                       Totals
ID       Risks                            Initial Risk                                                                              Controls                      Assurances               Reported Assurances           Current Risk Gaps in Controls      Gaps in Assurance   Action Plan   Who   When
                                            Rating                                                                                                                                         Identified in Board Reports   Rating JUN




                                                                          Intial (Inherent)
                                                                                                                                                                                           and External Assessments
                                       Consequence




                                                                                                                                                                                                                         Consequence
                                                     Likelihood




                                                                                                                                                                                                                                       Likelihood
                                                                                                                  MARCH
                                                                                              JUNE
                                                                                                     SEPT
                                                                                                            DEC
                                                                  Total




                                                                                                                                                                                                                                                    Total
     262 Patients whose discharge       5            4            20      20 10                      0      0      0 Bed Management Policy                  Audit of patient bed                                          5             2           10
         is delayed are at increased                                                                                                                        movements reported in
         risk of acquiring HCAI                                                                                           Bed Managers                      Patient Experience Report

                                                                                                                          Discharge Co-ordinators           Number of delayed
                                                                                                                                                            discharges reported
                                                                                                                          Care close to home multi          Patients are moved into
                                                                                                                          agency working party              community beds or
                                                                                                                          Director of Operations liaises    adequate nursing home
                                                                                                                          with PCT in relation to use of    provision in a timely manner
                                                                                                                          community beds                    - reported by exception to
                                                                                                                                                            Trust Board
                                                                                                                          Capacity Management Project

                                                                                                                          Project Manager-Clinical          Management Board reports
                                                                                                                          Systems Improvement
                                                                                                                          Social Service Manager with
                                                                                                                          Lead responsibility
                                                                                                                          Service Improvement Plan for
                                                                                                                          Adult Health and Social Care
                                                                                                                          agreed


     263 High bed occupancy             5            4            20      20 10                      0      0      0 Updated cleaning specification Ward audit clealiness             Results of Peat Report              5            2            10
         reduces time available for                                                                                       to enhance cleaning regimes in audits and Infection         Reported to Clinical
         proper cleaning of beds                                                                                          ward areas
                                                                                                                          On-call deep cleaning team     Prevention environmental     Governance Committee
         between patients                                                                                                                                audits reported via Matrons' (14/05/2009)
                                                                                                                          Bed management policy; bed PEAT inspection report
                                                                                                                          management meetings thrice
                                                                                                                          daily
                                                                                                                          Discharge co-ordinators meet      Audit of Patient
                                                                                                                          with operations director to       Movements/Patient
                                                                                                                          facilitate difficult discharges   Safety/Experience Reports

                                                                                                                          Terminal cleaning team in         Finance and Performance
                                                                                                                          place                             Reports
                                                                                                                          Capacity Management Project       Minutes of discharge
                                                                                                                                                            meetings
                                                                                                                          Project Manager - Clinical        Terminal clean check list
                                                                                                                          Systems Improvement               held by Hotel Services
                                                                                                                          Social Service Manager with       Clinical Governance & Trust
                                                                                                                          Lead responsibility               Board Meetings
                                                                                                                          Service Improvement Plan for
                                                                                                                          Adult Health and Social Care
                                                                                                                          agreed


                                                                                                       Current
                                                                                                       Totals




                                                                                                                                                                                           Collated by Pat Morris
                                                                                                                                                                                           Head of Governance                                                                                                5
             Enclosure Oi                                                                                                                                                                                                                                                              Objective 1

                                                                                                                                                                           Board Assurance Framework 2009-2010




ID       Risks                       Initial Risk                                                                              Controls                    Assurances             Reported Assurances            Current Risk Gaps in Controls      Gaps in Assurance   Action Plan   Who   When
                                       Rating                                                                                                                                     Identified in Board Reports    Rating JUN




                                                                     Intial (Inherent)
                                  Consequence                                                                                                                                     and External Assessments




                                                                                                                                                                                                                 Consequence
                                                Likelihood




                                                                                                                                                                                                                               Likelihood
                                                                                                             MARCH
                                                                                         JUNE
                                                                                                SEPT
                                                                                                       DEC
                                                             Total




                                                                                                                                                                                                                                            Total
     264 PCT fail to reduce        5            5            25                          10     0      0      0 County-wide meeting of DIPCs Minutes of DIPCs meeting            Incidence of Cdiff reduced as    5            2            10
         incidence of community                                                                                                                                                  reported to Infection
         HCAI                                                                                                        PCT Representative member       Minutes of IPB meeting      Prevention Board/Clinical
                                                                                                                     of Infection Prevention Board                               Governance Committee and
                                                                                                                                                                                 Trust Board
                                                                                                                     Health Protection Unit          Trust Board Minutes
                                                                                                                     Representation at Infection
                                                                                                                     Control Team Meetings
                                                                                                                     Clinical Quality Review Meeting Clinical Governance
                                                                                                                     with PCT                        Minutes
                                                                                                                     Community antibiotic            Patient Safety Report
                                                                                                                     prescribing policy




                                                                                                                                                                                   Collated by Pat Morris
                                                                                                                                                                                   Head of Governance                                                                                                6
              Enclosure Oi                                                                                                                                                                                                                                                                                                          Objective 2

                                                                                                                                                                     Board Assurance Framework 2009-2010




         Principle Objective 2:                                           The Trust will develop services that provide specialist care locally

         SfBH Domain                                                      Accessible & Responsive Care

         Lead Director                                                    Director of Development

Major Element                                                                                                                                                                                                                                Lead
                                                                                                                                                                                                                                                                                                                                          Deadline

2.1      Further develop the services at Stratford Hospital including expansion of the endoscopy service and surgical procedures                                                                                                             Director of Development                                                                      10/31/2009

                                                                                                       Current
                                                                                                       Totals
ID       Risks                            Initial Risk                                                                             Controls             Assurances         Reported Assurances            Current Risk Gaps in Controls                                  Gaps in Assurance               Action Plan             Who         When
                                            Rating                                                                                                                          Identified in Board Reports   Rating JUN
                                                                          Intial (Inherent)




                                                                                                                                                                            and External Assessments
                                       Consequence




                                                                                                                                                                                                          Consequence
                                                     Likelihood




                                                                                                                                                                                                                        Likelihood
                                                                                                                  MARCH
                                                                                              JUNE
                                                                                                     SEPT
                                                                                                            DEC
                                                                  Total




                                                                                                                                                                                                                                     Total
     389 Lack of available space at     3            4            12      12 12                      0      0      0 Project Team have reviewed                                                            3             4           12 Use of space currently           Findings of Pilot and      Opption appraisal for   Director of      9/30/2009
         Statford Hospital to expand                                                                                      Endoscopy Pilot                                                                                                    used by GU services not     refreshed business case    accommodating GU        Development
         services                                                                                                                                                                                                                            maximised                   for endoscopy not reported
                                                                                                                                                                                                                                             Site development plan for                              Develop a Site          Director of     10/31/2009
                                                                                                                                                                                                                                             Stratford Hospital                                     Development Plan for    Development
                                                                                                                                                                                                                                                                                                    Stratford Hospital
                                                                                                                                                                                                                                                                                                    Endoscopy paper to      Director of      7/10/2009
                                                                                                                                                                                                                                                                                                    Management Board        Development


     390 The financial and              3            4            12      12 12                      0      0      0 Original Business Case       Project Team Minutes                                     3             4           12                                  Findings of Pilot and      Endoscopy paper to      Director of      7/10/2009
         accomodation                                                                                                     Project Team            Updates at Management                                                                                                  refreshed business case    Management Board        Development
         consequence of meeting                                                                                                                   Board                                                                                                                  for endoscopy not reported
         statutory requirements for
         an effective
         decontamination system
         may inhibit expansion.




                                                                                                                                                                            Collated by Pat Morris
                                                                                                                                                                            Head of Governance                                                                                                                                                     7
              Enclosure Oi                                                                                                                                                                                                                                                                                                                        Objective 2

                                                                                                                                                                               Board Assurance Framework 2009-2010




Major Element                                                                                                                                                                                                                                          Lead
                                                                                                                                                                                                                                                                                                                                                            Deadline

2.2       Implement an Interventional Cardiology Service                                                                                                                                                                                               Director of Operations & Nursing                                                                     9/30/2009

                                                                                                       Current
                                                                                                       Totals
ID        Risks                           Initial Risk                                                                                 Controls                  Assurances           Reported Assurances           Current Risk Gaps in Controls                                    Gaps in Assurance              Action Plan                Who             When
                                            Rating                        Intial (Inherent)                                                                                           Identified in Board Reports   Rating JUN
                                                                                                                                                                                      and External Assessments
                                       Consequence




                                                                                                                                                                                                                    Consequence
                                                     Likelihood




                                                                                                                                                                                                                                  Likelihood
                                                                                                                  MARCH
                                                                                              JUNE
                                                                                                     SEPT
                                                                                                            DEC
                                                                  Total




                                                                                                                                                                                                                                               Total
     391 Current proposal may not       4            4            16      16 16                      0      0      0 Original Business Case                Report to Management                                      4             4           16 Business case needs                                          Revitalised business      Project Manager      30/06/2009
         get PCT, Cardiac Network                                                                                                                          Board                                                                                       updating                                                case to Management        Clinical Systems
         and BCIS approval                                                                                                                                                                                                                                                                                     Board for approval        Improvement
         because:                                                                                                         Finance Director discussed at    Executive F&P                                                                               Clinical Pathway for
                                                                                                                          Commissioner meetings                                                                                                        elective and emergency
         *Potentially insufficient                                                                                        Lead AMD and Project                                                                                                         patients                                                Clinical Pathway for   AMD for Medicine        31/07/2009
         numbers of elective                                                                                              Manager Clinical Systems                                                                                                                                                             elective and emergency
         patients                                                                                                         Improvement attends Cardiac                                                                                                                                                          patients to be agreed
                                                                                                                          Network meetings                                                                                                                                                                     and reported to
         *Savings to PCT would
         require a single procedure
                                                                                                                          Speciality Review meeting with
                                                                                                                          Cardiology


Major Element                                                                                                                                                                                                                                          Lead
                                                                                                                                                                                                                                                                                                                                                            Deadline

2.3       Provide a digital mammography service as part of the new breast Unit                                                                                                                                                                         Director of Development                                                                              12/31/2009

                                                                                                       Current
                                                                                                       Totals
ID        Risks                           Initial Risk                                                                                 Controls                  Assurances           Reported Assurances           Current Risk Gaps in Controls                                    Gaps in Assurance              Action Plan                Who             When
                                            Rating                                                                                                                                    Identified in Board Reports   Rating JUN
                                                                          Intial (Inherent)




                                                                                                                                                                                      and External Assessments
                                       Consequence




                                                                                                                                                                                                                    Consequence
                                                     Likelihood




                                                                                                                                                                                                                                  Likelihood
                                                                                                                  MARCH
                                                                                              JUNE
                                                                                                     SEPT
                                                                                                            DEC
                                                                  Total




                                                                                                                                                                                                                                               Total
     392 Insufficient funding to        4            3            12      12                  8      0      0      0 Capital Committee approved            Capital Committee         Capital Committee Meeting       4             2           8       Uncertain of the amount       Business case required to Agree fund raising plan   Director of           7/31/2009
         provide facility and                                                                                             allocation                                                 15/05/2009                                                        of additional funding         understand return on                                Development
         equipment                                                                                                                                                                                                                                     which will be raised          investment                Present Business Case
                                                                                                                                                                                                                                                       through charitable funds                                to Trust Board
                                                                                                                          Additional fundraising           Charity Trustees          Charity Trustees (10/06)


     393 Delayed or restricted          4            3            12      12 12                      0      0      0 Project team managing                 Management Board                                          4             3           12 Lack of clarity regarding                                    Identify access to site   Director of           7/31/2009
         access to site due to other                                                                                      deadlines                                                                                                                    timescales on other                                     and space for             Development
         building projects causes                                                                                                                                                                                                                      building projects                                       contractors
                                                                                                                                                           Capital Committee
         delays to the scheme
                                                                                                                                                                                                                                                       Integrated Project Plan for                             Agree Project Plans for Director of             7/31/2009
                                                                                                                                                                                                                                                       all schemes                                             all schemes highlighting Development
                                                                                                                                                                                                                                                                                                               interdependancies




                                                                                                                                                                                       Collated by Pat Morris
                                                                                                                                                                                       Head of Governance                                                                                                                                                               8
              Enclosure Oi                                                                                                                                                                                                                                                                                                              Objective 2

                                                                                                                                                                                 Board Assurance Framework 2009-2010




                                                                                                        Current
                                                                                                        Totals
ID        Risks                            Initial Risk                                                                              Controls                      Assurances           Reported Assurances           Current Risk Gaps in Controls                                Gaps in Assurance        Action Plan              Who             When
                                             Rating                                                                                                                                     Identified in Board Reports   Rating JUN



                                                                           Intial (Inherent)
                                                                                                                                                                                        and External Assessments
                                        Consequence




                                                                                                                                                                                                                      Consequence
                                                      Likelihood




                                                                                                                                                                                                                                    Likelihood
                                                                                                                   MARCH
                                                                                               JUNE
                                                                                                      SEPT
                                                                                                             DEC
                                                                   Total




                                                                                                                                                                                                                                                 Total
     394 Additional staffing required    4            2            8           8               8      0      0      0 Project team includes                   Management Board         Management Board minutes        4             2           8       Clarity of operating                          Operating procedures to Director of           8/31/2009
         due to lack of integration                                                                                        Aylesford Unit Staff                                        (12/06)                                                           processes between the                         be developed and        Development
         with Aylesford Unit                                                                                               Project Initiation Document                                                                                                   Aylesford unit and the                        agreed
                                                                                                                           includes integration of services                                                                                              new Breast unit
                                                                                                                           within its scope




Major Element                                                                                                                                                                                                                                            Lead
                                                                                                                                                                                                                                                                                                                                                  Deadline
2.4       Implement a service to support the delivery of intravenous drug therapy at home                                                                                                                                                                Director of Operations & Nursing                                                         12/31/2009
                                                         Current
ID        Risks                  Initial Risk                              Controls                                                                                Assurances           Reported Assurances           Current Risk Gaps in Controls                                Gaps in Assurance        Action Plan              Who             When
                                   Rating                                                                                                                                               Identified in Board Reports   Rating JUN
                                                                           Intial (Inherent)




                                                                                                                                                                                        and External Assessments
                                        Consequence




                                                                                                                                                                                                                      Consequence
                                                      Likelihood




                                                                                                                                                                                                                                    Likelihood
                                                                                                                   MARCH
                                                                                               JUNE
                                                                                                      SEPT
                                                                                                             DEC
                                                                   Total




                                                                                                                                                                                                                                                 Total
     395 Funding stream not              3            2            6           6               6      0      0      0                                         Management Board                                         3             2           6       Identify Funding Stream                       Business case for       GM for Medicine      31/12/2009
         identified by the Trust                                                                                                                                                                                                                                                                       delivering IV therapy

     396 Home IV therapy service         3            2            6           6               6      0      0      0                                         Management Board                                         3             2           6       Identify process                              Finance Director to     Finance Director     31/12/2009
         not commisioned by the                                                                                                                                                                                                                                                                        discuss with
         PCT                                                                                                                                                                                                                                                                                           Commissioners




                                                                                                                                                                                         Collated by Pat Morris
                                                                                                                                                                                         Head of Governance                                                                                                                                                9
             Enclosure Oi                                                                                                                                                                                                                                                                                                             Objective 2

                                                                                                                                                                        Board Assurance Framework 2009-2010




Major Element                                                                                                                                                                                                                                   Lead
                                                                                                                                                                                                                                                                                                                                            Deadline
2.5      Work with the PCT to develop community based 'expert' services                                                                                                                                                                         Director of Development                                                                     12/31/2009
                                                    Current
                                                    Totals
ID       Risks                 Initial Risk                            Controls                                                                           Assurances          Reported Assurances            Current Risk Gaps in Controls                                   Gaps in Assurance            Action Plan             Who          When
                                 Rating
                                                                         Intial (Inherent)                                                                                     Identified in Board Reports   Rating JUN
                                                                                                                                                                               and External Assessments
                                      Consequence




                                                                                                                                                                                                             Consequence
                                                    Likelihood




                                                                                                                                                                                                                           Likelihood
                                                                                                                 MARCH
                                                                                             JUNE
                                                                                                    SEPT
                                                                                                           DEC
                                                                 Total




                                                                                                                                                                                                                                        Total
     284 Unable to develop services    3            3            9           9               9      0      0      0 GP Meetings                      Management Board                                         3             3           9       Trust Strategy relating to   Reporting mechanisms for Trust Strategy to be    Director of     30/09/2009
         in the community because                                                                                                                                                                                                               Community Services           dissemination of outcomes updated to reflect     Development
         of lack of support from                                                                                                                                                                                                                needs updating               from CRG unclear          proposed changes to
         PCT/GP or lack of                                                                                               PCT Plans                                                                                                                                                                     Community Services as
         accomodation or lack of                                                                                         Service Development Plans                                                                                                                                                     being suggested by PCT
         resources                                                                                                       Clinical Reference Group                                                                                                                                                      and report to Board
                                                                                                                         (CRG) meetings
                                                                                                                         Active involvement in PCT                                                                                                                                                   Reporting Mechanisim    Director of      31/07/2009
                                                                                                                         Programme- Transforming                                                                                                                                                     for CRG to be agreed    Development
                                                                                                                         Community Services




Major Element                                                                                                                                                                                                                                   Lead
                                                                                                                                                                                                                                                                                                                                            Deadline

2.6      Use the market analysis and patient feedback to identify areas where services can be developed - No risks identified                                                                                                                   Director of Development                                                                     Ongoing




                                                                                                                                                                               Collated by Pat Morris
                                                                                                                                                                               Head of Governance                                                                                                                                                   10
             Enclosure Oi                                                                                                                                                                                                                                                                                                                Objective 3

                                                                                                                                                                           Board Assurance Framework 2009-2010




          Principle Objective 3:                                            The Trust will ensure it has sufficient capacity to meet demand

          SfBH Domain                                                       Accessible & Responsive Care

          Lead Director                                                     Director of Development

Major Element                                                                                                                                                                                                                                        Lead
                                                                                                                                                                                                                                                                                                                                                   Deadline
          Determine bed requirements for the next 5 years and agree a capacity plan to provide the appropriate bed, theatre and staffing
3.1                                                                                                                                                                                                                                                  Director of Development                                                                       6/30/2009
          required to support planned activity
                                                       Current
                                                        Totals
ID        Risks                  Initial Risk                            Controls               Assurances        Reported Assurances                                                                             Current Risk Gaps in Controls                                 Gaps in Assurance        Action Plan                  Who             When
                                   Rating                                                                          Identified in Board Reports                                                                    Rating JUN
                                                                            Intial (Inherent)




                                                                                                                                                                                   and External Assessments
                                         Consequence




                                                                                                                                                                                                                  Consequence
                                                       Likelihood




                                                                                                                                                                                                                                Likelihood
                                                                                                                    MARCH
                                                                                                JUNE
                                                                                                       SEPT
                                                                                                              DEC
                                                                    Total




                                                                                                                                                                                                                                             Total
     397 The assumptions used to          4            3            12      12 12                      0      0      0 Specialty specific plan          Trust Board                                                4             3           12 Process to refresh                                  Process to be agreed         Project Manager       7/31/2009
         calculate capacity plan are                                                                                                                                                                                                                 assumptions                                    including reporting          - Clinical
         wrong                                                                                                                                                                                                                                                                                      mechanisms                   Systems
                                                                                                                                                        Management Board                                                                             Updates of Specialty                           Rolling programme of         Improvement
                                                                                                                                                                                                                                                                                                                                 Project Manager       8/31/2009
                                                                                                                                                                                                                                                     specific plans                                 updates to be                - Clinical
                                                                                                                                                                                                                                                                                                    implemented                  Systems
                                                                                                                                                                                                                                                                                                                                 Improvement

     398 Failure to deliver additional    4            4            16      16 12                      0      0      0 Approved Business Case           Trust Board              Trust Board Minutes (28/05)       4             3           12 Planning Permission                                 Obtain Planning              Director of         9/30/2009
         bed capacity for Winter                                                                                            Project Team for new ward                                                                                                                                               Permission                   Development
                                                                                                                            Project Plan
                                                                                                                            Tenders received and
                                                                                                                            approvedfor project
                                                                                                                            Risk Log


     399 Fail to recruit to new           4             3           12      12                  8      0      0      0 Project Team                     Management Board         Good progress with                4            2            8                                                      Implement action plans       GM for Medicine      11/30/2009
         staffing structure                                                                                                 Locums in place             Executive F&P            recruitemnt especially nursing                                                                                     identified on project risk
                                                                                                                                                                                 reported at Management                                                                                             log
                                                                                                                            Job Descriptions
                                                                                                                                                                                 Board (12/06)
                                                                                                                            Recruitment Plan
                                                                                                                                                                                 Executive F&P meeting
                                                                                                                                                                                 26/05/2009


     400 New medical arrangements         4            3            12      12 12                      0      0      0 Process added as a standing      Management Board                                           4            3            12 Confused timetable for                              Agree implementation         AMDs and GM           6/30/2009
         do not deliver improved                                                                                            agenda item on Consultant                                                                                                delivery                                       date with Physcians          Medicine
         processes                                                                                                          physician meeting
                                                                                                                                                                                                                                                     Lack of full support for                       Develop specific             Project Manager      30/10/2009
                                                                                                                            Process agreed at                                                                                                        medical cover                                  measures and collection      - Clinical
                                                                                                                            Management Board                                                                                                         arrangements                                   methods as part of the       Systems
                                                                                                                                                                                                                                                                                                    Health Foundation            Improvement
                                                                                                                                                                                                                                                                                                    Project

Major Element                                                                                                                                                                                                                                        Lead
                                                                                                                                                                                                                                                                                                                                                   Deadline
          Complete a pilot on Nicol ward at Stratford Hospital to access the benefits of the Trust permanently managing this Facility -
3.2                                                                                                                                                                                                                                                  Director of Operations & Nursing                                                              3/31/2010
          Pilot abandoned




                                                                                                                                                                                  Collated by Pat Morris
                                                                                                                                                                                  Head of Governance                                                                                                                                                       11
             Enclosure Oi                                                                                                                                                                                                                                                                                                                             Objective 3

                                                                                                                                                                              Board Assurance Framework 2009-2010




         Implement the first phase of the Radiology development plan to include improved provision in A&E and upgrading of
3.3                                                                                                                                                                                                                                                            Director of Development                                                                         12/31/2009
         equipment in the main department
                                                       Current
                                                        Totals
ID       Risks                  Initial Risk                             Controls            Assurances        Reported Assurances                                                                                  Current Risk Gaps in Controls                                            Gaps in Assurance           Action Plan               Who            When
                                  Rating                                                                       Identified in Board Reports                                                                          Rating JUN

                                                                          Intial (Inherent)
                                                                                                                                                                                      and External Assessments
                                       Consequence




                                                                                                                                                                                                                    Consequence
                                                     Likelihood




                                                                                                                                                                                                                                      Likelihood
                                                                                                                  MARCH
                                                                                              JUNE
                                                                                                     SEPT
                                                                                                            DEC
                                                                  Total




                                                                                                                                                                                                                                                       Total
     401 Lack of Capital resources      5            3            15      15 20                      0      0      0 Business Case for CT and MRI Maangment Board                   Management Board meetings        5                 4               20 Lack of funding                                           Gain approval of          Director of        6/30/2009
         to implement plan                                                                                                Scanner approved by                                       (12/06)                                                                                                                         Application for funding   Development
                                                                                                                          Managment Board                                                                                                                                                                           by DoH
                                                                                                                          Application for funding to DoH
                                                                                                                          supported by the StHa

     402 Lack of space and access       5            3            15      15 15                      0      0      0 Breast Unit Scheme approved Capital Committtee                 Capital Committee Meeting                     5                3   15 Lack of clarity regarding                                 Identify access to site   Director of          7/31/2009
         to site restricted by other                                                                                      by Capital Committee                                      15/05/2009                                                                 timescales on other                                  and space for             Development
         schemes prevents                                                                                                                                                                                                                                      building projects                                    contractors
         implementation within                                                                                                                             Management Board                                                                                    Integrated Project Plan for                          Agree Project Plans for Director of            7/31/2009
         required timescales                                                                                                                                                                                                                                   all schemes                                          all schemes highlighting Development
                                                                                                                                                                                                                                                                                                                    interdependancies



Major Element                                                                                                                                                                                                                                                  Lead
                                                                                                                                                                                                                                                                                                                                                               Deadline

3.4      Develop a plan for Maternity Services for the next 5 years - No risks identified                                                                                                                                                                      Director of Development                                                                         6/30/2009


Major Element                                                                                                                                                                                                                                                  Lead
                                                                                                                                                                                                                                                                                                                                                               Deadline

3.5      Develop Palliative Care Services to support appropriate End of Life Care for patients                                                                                                                                                                 Medical Director                                                                                9/30/2009

                                                                                                       Current
                                                                                                       Totals
ID       Risks                            Initial Risk                                                                              Controls                    Assurances           Reported Assurances            Current Risk Gaps in Controls                                            Gaps in Assurance           Action Plan               Who            When
                                            Rating                                                                                                                                    Identified in Board Reports   Rating JUN
                                                                          Intial (Inherent)




                                                                                                                                                                                      and External Assessments
                                       Consequence




                                                                                                                                                                                                                    Consequence
                                                     Likelihood




                                                                                                                                                                                                                                      Likelihood
                                                                                                                  MARCH
                                                                                              JUNE
                                                                                                     SEPT
                                                                                                            DEC
                                                                  Total




                                                                                                                                                                                                                                                       Total
     403 Inadequate internal            4            4            16      16 16                      0      0      0 Palliative Care Consultant                                                                      4                 4               16 Poor implementation of             Issues not reported    Process for reporting     AGM for Cancer      31/07/2009
         resources to deliver End of                                                                                                                                                                                                                           the Liverpool Care            through the Trust      issues to be identified   Services
         Life Care                                                                                                        Lead Palliative Care Nurse                                                                                                           Pathway                       Committee Structures   and actioned
                                                                                                                          Cancer Unit                                                                                                                          Understanding of                                     Scoping of Trust's       Lead Palliative      31/08/2009
                                                                                                                                                                                                                                                               resources required                                   Palliative Care Services Care Nurse
                                                                                                                          Liverpool Care Pathway
                                                                                                                                                                                                                                                                                                                    and gaps identified and
                                                                                                                          Community Supportive Care                                                                                                            Limited remit for                                    reported to Clinical
                                                                                                                          Pathway Facilitators                                                                                                                 Community Supportive                                 Governance Committee
                                                                                                                                                                                                                                                               Care Pathway Facilitators




                                                                                                                                                                                     Collated by Pat Morris
                                                                                                                                                                                     Head of Governance                                                                                                                                                                12
             Enclosure Oi                                                                                                                                                                                                                                                                                                                       Objective 3

                                                                                                                                                                            Board Assurance Framework 2009-2010




                                                                                                        Current
                                                                                                        Totals
ID        Risks                            Initial Risk                                                                             Controls                 Assurances            Reported Assurances            Current Risk Gaps in Controls                                       Gaps in Assurance           Action Plan               Who            When
                                             Rating                                                                                                                                 Identified in Board Reports   Rating JUN




                                                                           Intial (Inherent)
                                                                                                                                                                                    and External Assessments
                                        Consequence




                                                                                                                                                                                                                  Consequence
                                                      Likelihood




                                                                                                                                                                                                                                    Likelihood
                                                                                                                   MARCH
                                                                                               JUNE
                                                                                                      SEPT
                                                                                                             DEC
                                                                   Total




                                                                                                                                                                                                                                                     Total
     404 Lack of clarity concerning      4            4            16      16 16                      0      0      0 MHS Warwickshire End of Life                                                                 4                 4               16 Implication of the Strategy Issues not reported      Process for reporting     AGM for Cancer      31/07/2009
         community resources                                                                                               Care Strategy                                                                                                                     for the Trust            through the Trust      issues to be identified   Services
         relating to End of Life Care                                                                                                                                                                                                                                                 Committee Structures   and actioned

                                                                                                                                                                                                                                                                                                             Strategy to be reviewed   Director of          7/31/2009
                                                                                                                                                                                                                                                                                                             and implications for      Nursing &
                                                                                                                                                                                                                                                                                                             Trust identified and      Operations
                                                                                                                                                                                                                                                                                                             reported



Major Element                                                                                                                                                                                                                                                Lead
                                                                                                                                                                                                                                                                                                                                                        Deadline
          Implement improved processes for the management of patients admitted for unscheduled care including the discharge
3.6                                                                                                                                                                                                                                                          Director of Operations & Nursing                                                           9/30/2009
          processes
                                                     Current
                                                     Totals
ID        Risks                Initial Risk                            Controls            Assurances         Reported Assurances                                                                                 Current Risk Gaps in Controls                                       Gaps in Assurance           Action Plan               Who            When
                                 Rating                                                                        Identified in Board Reports                                                                        Rating JUN
                                                                           Intial (Inherent)




                                                                                                                                                                                    and External Assessments
                                        Consequence




                                                                                                                                                                                                                  Consequence
                                                      Likelihood




                                                                                                                                                                                                                                    Likelihood
                                                                                                                   MARCH
                                                                                               JUNE
                                                                                                      SEPT
                                                                                                             DEC
                                                                   Total




                                                                                                                                                                                                                                                     Total
     405 Fail to get Consultant          4            3            12      12 12                      0      0      0 Consultant Physcians have        Consultant Meeting         Consultant Physcians meeting     4                 3               12 Ensuring Physcians are        Reporting structure    Communications Plan to GM for Medicine        30/06/2009
         Physcian's support                                                                                                agreed the new medical                                 02/04/2009                                                                 aware of progress                               Management Board for
                                                                                                                           process                                                                                                                                                                           approval
                                                                                                                           Document outlining the       Management Board          Consultant Physcians meeting                                                                                               Regular Agenda Item on GM for Medicine          Ongoing
                                                                                                                           proposed new medical process                           05/06/2009 agreed a                                                                                                        Consultant Physcians
                                                                                                                                                        Executive F&P             staggered start date from the                                                                                              meeting and Mangement
                                                                                                                                                                                  01/08/2009                                                                                                                 Board Agenda and
                                                                                                                                                                                                                                                                                                             Executive F&P

     406 Fail to appoint sufficient      4            3            12      12                  8      0      0      0 Job Descriptions                 Executive F&P              Executive F&P meeting            4                 2               8       Ensuring Physcians are   Reporting structure    Communications Plan to GM for Medicine        30/06/2009
         staff to implement and                                                                                                                                                   26/05/2009                                                                 aware of Progress                               Management Board
         maintain the new medical
                                                                                                                           Recruitment Plan            Management Board                                                                                                                                      Regular Agenda Item on GM for Medicine          Ongoing
         process
                                                                                                                                                                                                                                                                                                             Consultant Physcians
                                                                                                                                                                                                                                                                                                             meeting and Mangement
                                                                                                                                                                                                                                                                                                             Board Agenda



     407 Not being able to identify      4            4            16      16 16                      0      0      0 Annual Job Plans Review by       Finance & Perfomance                                                     4                4   16 All parties involved do not                          Develop timetable and     AMDs and GM          6/30/2009
         sufficient additional PAs in                                                                                      AMDs supported by AGMs      Executive                                                                                             have a clear                                    agree process for job     Medicine
         the job review process to                                                                                                                                                                                                                           understanding of the                            planning
         support acute physcians                                                                                                                                                                                                                             process and
         appointments                                                                                                                                                                                                                                        responsibilities




                                                                                                                                                                                   Collated by Pat Morris
                                                                                                                                                                                   Head of Governance                                                                                                                                                           13
              Enclosure Oi                                                                                                                                                                                                                                                                                                                              Objective 3

                                                                                                                                                                                Board Assurance Framework 2009-2010




                                                                                                          Current
                                                                                                          Totals
ID        Risks                              Initial Risk                                                                              Controls                   Assurances           Reported Assurances            Current Risk Gaps in Controls                                            Gaps in Assurance          Action Plan               Who              When
                                               Rating                                                                                                                                   Identified in Board Reports   Rating JUN




                                                                             Intial (Inherent)
                                                                                                                                                                                        and External Assessments
                                          Consequence




                                                                                                                                                                                                                      Consequence
                                                        Likelihood




                                                                                                                                                                                                                                        Likelihood
                                                                                                                     MARCH
                                                                                                 JUNE
                                                                                                        SEPT
                                                                                                               DEC
                                                                     Total




                                                                                                                                                                                                                                                         Total
     408 New emergency care                5            3            15      15 15                      0      0      0 Process added as a standing          MOAGG                    Finance & Performance                         5                3   15 Collection methodology                                   Develop specific        Health                  31/09/2009
         pathway fails to reduce                                                                                             agenda item on Consultant                                Executive                                                                  not yet in place for some                           measures and collection Foundation
         HSMR, reduce LOS and                                                                                                physician meeting                                                                                                                   of identified criteria                              methods as part of the  Project Lead
         improve outcomes for the                                                                                                                                                                                                                                                                                    Health Foundation
         patients                                                                                                            Health Foundation Project       Management Board         Consultant Physcians meeting                                               Complete full set of                                Project
                                                                                                                                                                                      05/06/2009 agreed success                                                  process improvement
                                                                                                                                                                                      criteria                                                                   measures
                                                                                                                             Some success criteria have
                                                                                                                             been identified


     409 Fail to implement CQUIN           3            3            9           9               9      0      0      0 Project Managers for both            Capacity Management                                                    3                3   9       Project definitions and       Reporting structure   Agree project definitions Director of            7/31/2009
         Schemes to improve                                                                                                  schemes identified              Project Meeting                                                                                     criteria for success                                and criteria for success Operations
         discharge processes which                                                                                                                                                                                                                                                                                   with PCT
                                                                                                                             Project Plans                                                                                                                       Clinical engagement
         will also result in a loss of
         income
                                                                                                                             Daily monitoring of expected                                                                                                                                                            Reporting mechanisms      Director of            6/30/2009
                                                                                                                             date of discharge in place                                                                                                                                                              to be identified and      Operations
                                                                                                                                                                                                                                                                                                                     communicated

                                                                                                                                                                                                                                                                                                                     AMDs to Champion          AMDs in Medicine        Ongoing
                                                                                                                                                                                                                                                                                                                     process with Physcians
                                                                                                                                                                                                                                                                                                                     to get clinical
                                                                                                                                                                                                                                                                                                                     engagement



Major Element                                                                                                                                                                                                                                                    Lead
                                                                                                                                                                                                                                                                                                                                                                  Deadline

3.7       Develop a Site Development Plan with input from key stakeholders and communicate the agreed plan to all stakeholders                                                                                                                                   Director of Development                                                                          12/31/2009

                                                                                                          Current
                                                                                                          Totals
ID        Risks                              Initial Risk                                                                              Controls                   Assurances           Reported Assurances            Current Risk Gaps in Controls                                            Gaps in Assurance          Action Plan               Who              When
                                               Rating                                                                                                                                   Identified in Board Reports   Rating JUN
                                                                             Intial (Inherent)




                                                                                                                                                                                        and External Assessments
                                          Consequence




                                                                                                                                                                                                                      Consequence
                                                        Likelihood




                                                                                                                                                                                                                                        Likelihood
                                                                                                                     MARCH
                                                                                                 JUNE
                                                                                                        SEPT
                                                                                                               DEC
                                                                     Total




                                                                                                                                                                                                                                                         Total
     410 Lack of clarity concerning        3            4            12      12                  0      0      0      0 Capital Committee                                                                                                                0       Uncertainty regarding                               Develop a plan that can   Director of           31/12/2009
         future capital availability to                                                                                                                                                                                                                          future capital availability                         be implemented over a     Development
         support site development                                                                                                                                                                                                                                                                                    flexible period of time
                                                                                                                             Long Term Financial Model                                                                                                                                                               depending on resource
                                                                                                                             based on existing assumptions                                                                                                                                                           available time be




                                                                                                                                                                                       Collated by Pat Morris
                                                                                                                                                                                       Head of Governance                                                                                                                                                                 14
             Enclosure Oi                                                                                                                                                                                                                                                                                                           Objective 3

                                                                                                                                                                             Board Assurance Framework 2009-2010




Major Element                                                                                                                                                                                                                                         Lead
                                                                                                                                                                                                                                                                                                                                              Deadline

3.8      Ensure there are sufficient appointment slots to support patients using the Choose and Book System                                                                                                                                           Director of Operations & Nursing                                                        Ongoing

                                                                                                       Current
                                                                                                       Totals
ID       Risks                            Initial Risk                                                                              Controls                  Assurances            Reported Assurances            Current Risk Gaps in Controls                             Gaps in Assurance        Action Plan                Who             When
                                            Rating                                                                                                                                   Identified in Board Reports   Rating JUN
                                                                          Intial (Inherent)                                                                                          and External Assessments
                                       Consequence




                                                                                                                                                                                                                   Consequence
                                                     Likelihood




                                                                                                                                                                                                                                 Likelihood
                                                                                                                  MARCH
                                                                                              JUNE
                                                                                                     SEPT
                                                                                                            DEC
                                                                  Total




                                                                                                                                                                                                                                              Total
     411 Patients unable to book on     3            4            12      12 12                      0      0      0 18 referral to treatment target    Weekly Workload Planning                                    3             4           12 Enough capacity to meet                         Specialties to identify    AGMs for               Ongoing
         to Choose and Book                                                                                                                             Meeting                                                                                       demand                                     capacity in a timely       Specialty
         because of lack of                                                                                               13 week maximum waiting time F&P Executive                                                                                                                             manner
                                                                                                                                                                                                                                                                                                 Implement Booking          GM for Support         Ongoing
         available capacity                                                                                               for an OPD appointment                                                                                                                                                 Service Improvement        Services
                                                                                                                          Outpatient PTL                                                                                                                                                         Paln
                                                                                                                          Choose & Book Team


     412 Short notice cancellation      3            4            12      12 12                      0      0      0 18 referral to treatment target    Weekly Workload Planning                                    3             4           12 Medical Staff Leave                             Medical Staff Leave        GM for                9/30/2009
         and rescheduling of                                                                                                                            Meeting                                                                                       Policy                                     Policy to be written and   Surgery/Medical
         appointments reduces                                                                                                                                                                                                                                                                    agreed by the              Director
                                                                                                                          13 week maximum waiting time F&P Executive
         capacity                                                                                                                                                                                                                                                                                appropraite group
                                                                                                                          for an OPD appointment
                                                                                                                          Outpatient PTL               Clinic Change Process
                                                                                                                          Choose & Book Team


     413 Inappropriate referrals by     2            3            6           6               6      0      0      0 Clinical Feedback                                                                              2            3            6       Patients seen in the                       Develop an electronic    Business                9/30/2009
         GPs and Practice staff due                                                                                                                                                                                                                   appropraite clinic                         process to identify when Improvement
         to a lack of understanding                                                                                                                                                                                                                                                              patient has been         Facilitator
         and engagement with the                                                                                                                                                                                                                                                                 referred into the wrong
         Choose & Book Process                                                                                                                                                                                                                                                                   clinic prior to arrival




Major Element                                                                                                                                                                                                                                         Lead
                                                                                                                                                                                                                                                                                                                                              Deadline

3.9      Implement the plan to increase car parking capacity                                                                                                                                                                                          Director of Development                                                                 9/30/2009

                                                                                                       Current
                                                                                                       Totals
ID       Risks                            Initial Risk                                                                              Controls                  Assurances            Reported Assurances            Current Risk Gaps in Controls                             Gaps in Assurance        Action Plan                Who             When
                                            Rating                                                                                                                                   Identified in Board Reports   Rating JUN
                                                                          Intial (Inherent)




                                                                                                                                                                                     and External Assessments
                                       Consequence




                                                                                                                                                                                                                   Consequence
                                                     Likelihood




                                                                                                                                                                                                                                 Likelihood
                                                                                                                  MARCH
                                                                                              JUNE
                                                                                                     SEPT
                                                                                                            DEC
                                                                  Total




     415 Delays to pathology                                                                                                                                                                                                                  Total
                                        4            3            12      12                  8      0      0      0 Funding allocated                  Capital Committtee         Capital Programme                4             2           8
         demolition delay additional
         spaces within the plan

                                                                                                                          Project Plan for Demolition
                                                                                                                          Car parking plan              Car Parking Group




                                                                                                                                                                                    Collated by Pat Morris
                                                                                                                                                                                    Head of Governance                                                                                                                                                15
             Enclosure Oi                                                                                                                                                                                                                                                                                                            Objective 3

                                                                                                                                                                    Board Assurance Framework 2009-2010




                                                                                                       Current
                                                                                                       Totals
ID       Risks                            Initial Risk                                                                              Controls             Assurances        Reported Assurances            Current Risk Gaps in Controls                                  Gaps in Assurance          Action Plan                  Who              When
                                            Rating                                                                                                                          Identified in Board Reports   Rating JUN




                                                                          Intial (Inherent)
                                                                                                                                                                            and External Assessments
                                       Consequence




                                                                                                                                                                                                          Consequence
                                                     Likelihood




                                                                                                                                                                                                                        Likelihood
                                                                                                                  MARCH
                                                                                              JUNE
                                                                                                     SEPT
                                                                                                            DEC
                                                                  Total




                                                                                                                                                                                                                                     Total
     416 Large numbers of               4            3            12      12                  8      0      0      0 50 Additional spaces procured                                                         4             2           8       Implementation of 1.5      Impact of initiative   Initiative to be             GM for support         8/31/2009
         contractors on -site absorb                                                                                      to support site development                                                                                        mile exclusion for parking unknown                implemented                  services
         additional capacity                                                                                              plans                                                                                                              to be implemented

                                                                                                                          High priority users car park                                                                                                                                         Impact of initiative to be   GM for support          31/09/09
                                                                                                                          reprovided                                                                                                                                                           assessed                     services
                                                                                                                          Car park plan includes                                                                                                                                               Additional spaces to be      GM for support          31/09/09
                                                                                                                          assumption for contractors'                                                                                                                                          procured if required         services
                                                                                                                          space.


Major Element                                                                                                                                                                                                                                Lead
                                                                                                                                                                                                                                                                                                                                               Deadline

3.10     Complete Job Plan Reviews for all Trust Consultants                                                                                                                                                                                 Medical Director                                                                                  3/31/2010

                                                                                                       Current
                                                                                                       Totals
ID       Risks                            Initial Risk                                                                              Controls             Assurances        Reported Assurances            Current Risk Gaps in Controls                                  Gaps in Assurance          Action Plan                  Who              When
                                            Rating                                                                                                                          Identified in Board Reports   Rating JUN
                                                                          Intial (Inherent)




                                                                                                                                                                            and External Assessments
                                       Consequence




                                                                                                                                                                                                          Consequence
                                                     Likelihood




                                                                                                                                                                                                                        Likelihood
                                                                                                                  MARCH
                                                                                              JUNE
                                                                                                     SEPT
                                                                                                            DEC
                                                                  Total




                                                                                                                                                                                                                                     Total
     414 Insufficient AMD time to       2            3            6           6               6      0      0      0 Regular meetings with AMDs to Report from MyJobPlan                                   2             3           6                                   No formal reporting   Interrogation of             Medical Director       7/31/2009
         complete reviews                                                                                                 discuss progress                                                                                                                               mechanism             MyJobPlan at quarterly
                                                                                                                                                                                                                                                                                               intervals with report to
                                                                                                                          AMDs prioritise their time
                                                                                                                                                                                                                                                                                               Trust Management
                                                                                                                          MyJobPlan Consultant List                                                                                                                                            Team


     417 Lack of consultant co-         2            4            8           8               8      0      0      0 Regular meetings with AMDs to Report from MyJobPlan                                   2             4           8                                   No formal reporting   Interrogation of             Medical Director       7/31/2009
         operation                                                                                                        discuss progress                                                                                                                               mechanism             MyJobPlan at quarterly
                                                                                                                          Contractual obligation to                                                                                                                                            intervals with report to
                                                                                                                          engage in job plan reviews                                                                                                                                           Trust Management
                                                                                                                                                                                                                                                                                               Team




                                                                                                                                                                           Collated by Pat Morris
                                                                                                                                                                           Head of Governance                                                                                                                                                          16
             Enclosure Oi                                                                                                                                                                                                                                                                                        Objective 4

                                                                                                                                                                              Board Assurance Framework 2009-2010




         Principle Objective 4:                                           The Trust will maintain financial stability

         SfBH Domain                                                      Governance

         Lead Director                                                    Finance Director

Major Element                                                                                                                                                                                                                                          Lead
                                                                                                                                                                                                                                                                                                                     Deadline
         Deliver sufficient surplus to support investment in facilities and support the provision of resources required to deliver the
4.1                                                                                                                                                                                                                                                    Director of Finance                                           On-going
         planned activity
                                                       Current
                                                        Totals
ID       Risks                   Initial Risk                               Controls              Assurances        Reported Assurances                                                                             Current Risk Gaps in Controls                            Gaps in Assurance   Action Plan   Who      When
                                   Rating                                                                            Identified in Board Reports                                                                    Rating JUN
                                                                          Intial (Inherent)




                                                                                                                                                                                         and External Assessments
                                       Consequence




                                                                                                                                                                                                                    Consequence
                                                     Likelihood




                                                                                                                                                                                                                                  Likelihood
                                                                                                                  MARCH
                                                                                              JUNE
                                                                                                     SEPT
                                                                                                            DEC
                                                                  Total




                                                                                                                                                                                                                                               Total
     418 Underperformance - plan        4            3            12      12 12                      0      0      0 F&P Executive will monitor           Monthly F&P Executive and                                  4             3           12
         assumes growth on                                                                                                activity V plan and agree any   Board reporting highlighting
         2008/09 outturn - this may                                                                                       mitigating actions. Contract    variances and any required
         not occur given the                                                                                              with main PCT has a floor       actions.
         significant rise in 2009/10                                                                                      which limits Trusts risk.




     419 Failure to deliver planned     4            3            12      12 12                      0      0      0 F&P Executive will monitor            Monthly F&P Executive and                                 4             3           12
         cost improvement target                                                                                          monthly via new more granular Board reporting highlighting
                                                                                                                          analysis highlighting shortfalls variances and any required
                                                                                                                          and mitigations. Any exception actions.
                                                                                                                          will be reported to board.




     420 Warwickshire PCT financial     4            4            16      16 16                      0      0      0 F&P Executive will monitor           Monthly F&P Executive and                                  4             4           16
         position - currently £24m                                                                                        activity V plan and agree any   Board reporting highlighting
         gap for 2009/10 and                                                                                              mitigating actions. Contract    variances and any required
         savings prgoramme will                                                                                           with main PCT has a floor       actions.
         look to reduce level of                                                                                          which limits Trusts risk.
         money into acute services




                                                                                                                                                                                         Collated by Pat Morris
                                                                                                                                                                                         Head of Governance                                                                                                                     17
             Enclosure Oi                                                                                                                                                                                                                                                                                                                          Objective 4

                                                                                                                                                                                 Board Assurance Framework 2009-2010




Major Element                                                                                                                                                                                                                                            Lead
                                                                                                                                                                                                                                                                                                                                                        Deadline
                                                                                                                                                                                                                                                                                                                                                        30/09/2009 &
4.2      Deliver sufficient surplus to make agreed loan repayments                                                                                                                                                                                       Director of Finance                                                                            31/03/2010

                                                                                                       Current
                                                                                                       Totals
ID       Risks                            Initial Risk                                                                              Controls                     Assurances             Reported Assurances           Current Risk Gaps in Controls                                Gaps in Assurance               Action Plan              Who             When
                                            Rating                                                                                                                                      Identified in Board Reports   Rating JUN
                                                                          Intial (Inherent)
                                                                                                                                                                                        and External Assessments
                                       Consequence




                                                                                                                                                                                                                      Consequence
                                                     Likelihood




                                                                                                                                                                                                                                    Likelihood
                                                                                                                  MARCH
                                                                                              JUNE
                                                                                                     SEPT
                                                                                                            DEC
                                                                  Total




                                                                                                                                                                                                                                                 Total
     421 Medical staffing costs         5            2            10      10 10                      0      0      0 Monthly reporting through F&P F&P Executive and Board                                             5             2           10
         continue to overspend                                                                                            Executive and variance and       Reports.
         reducing the Trusts ability                                                                                      mitigation actions included.
         to make appropriate                                                                                              Exceptions and mitigations
         repayments and deliver the                                                                                       reported to Board.
         required surplus.




Major Element                                                                                                                                                                                                                                            Lead
                                                                                                                                                                                                                                                                                                                                                        Deadline

4.3      Implement processes to make further improvements in the recording of accurate coding of patients                                                                                                                                                Director of Finance                                                                                  9/30/2009

                                                                                                       Current
                                                                                                       Totals
ID       Risks                            Initial Risk                                                                              Controls                     Assurances             Reported Assurances           Current Risk Gaps in Controls                                Gaps in Assurance               Action Plan              Who             When
                                            Rating                                                                                                                                      Identified in Board Reports   Rating JUN
                                                                          Intial (Inherent)




                                                                                                                                                                                        and External Assessments
                                       Consequence




                                                                                                                                                                                                                      Consequence
                                                     Likelihood




                                                                                                                                                                                                                                    Likelihood
                                                                                                                  MARCH
                                                                                              JUNE
                                                                                                     SEPT
                                                                                                            DEC
                                                                  Total




                                                                                                                                                                                                                                                 Total
422      Incomplete documentation       5            3            15      15 10                      0      0      0 Clinical Coders                       Management Board                                            5             2           10 Incomplete discharge           Validating the            Mortality Group to be set- Medical              30/11/2009
         and coding of co-                                                                                                                                                                                                                               summaries                 documentation is complete up chaired by the          Director
         morbidities                                                                                                      3 Accredidtaed Clincal Coders Patient Safety Group                                                                             Lack of availability of                             Medical Director
                                                                                                                                                                                                                                                         case-notes for coding
                                                                                                                          1 Accreditated Clinical Coder    Data Quality report                                                                                                     Reporting mechanisms for ToR of DQ Group to be       Associate            31/07/2009
                                                                                                                          Auditor                                                                                                                                                  data quality within the  reviewed to establish       Director for
                                                                                                                                                                                                                                                                                   revised committee        reporting mechanism         Information &
                                                                                                                          Coding validated using NHS       Payment by Results (PbR)
                                                                                                                                                                                                                                                                                   structure                                            Performance
                                                                                                                          HRG Grouper                      Clinical Coding Audits
                                                                                                                          Audit Red Flags alerting in Dr   Trust Commissioned                                                                                                                                 To establish reporting    Medical              31/07/2009
                                                                                                                          Foster Real Time Monitoring      External Clinical Coding                                                                                                                           mechanism for the         Director
                                                                                                                          Tool                             Audit                                                                                                                                              Discharge Summary
         Also on 9.4                                                                                                                                       Internal Clinical Coding                                                                                                                           Group
                                                                                                                                                           Audits


     423 Unable to produce dataset      4            1            4           4               4      0      0      0 Project plan                          Project Board                                               4            1            4
         for invoicing following PAS
         upgrade.                                                                                                                                          Management Board




                                                                                                                                                                                        Collated by Pat Morris
                                                                                                                                                                                        Head of Governance                                                                                                                                                         18
             Enclosure Oi                                                                                                                                                                                                                                                                                                                 Objective 4

                                                                                                                                                                           Board Assurance Framework 2009-2010




Major Element                                                                                                                                                                                                                                         Lead
                                                                                                                                                                                                                                                                                                                                                 Deadline

4.4      Ensure service line reporting is utilised within the Divisions.                                                                                                                                                                              Director of Finance                                                                            3/31/2010

                                                                                                        Current
                                                                                                        Totals
ID       Risks                             Initial Risk                                                                             Controls                  Assurances             Reported Assurances           Current Risk Gaps in Controls                                   Gaps in Assurance        Action Plan               Who           When
                                             Rating                                                                                                                                  Identified in Board Reports   Rating JUN
                                                                           Intial (Inherent)
                                                                                                                                                                                     and External Assessments
                                        Consequence




                                                                                                                                                                                                                   Consequence
                                                      Likelihood




                                                                                                                                                                                                                                 Likelihood
                                                                                                                   MARCH
                                                                                               JUNE
                                                                                                      SEPT
                                                                                                             DEC
                                                                   Total




                                                                                                                                                                                                                                              Total
     424 Failure to agree ground         3            3            9           9               9      0      0      0 SLR/SLM group tasked with         Report through to F&P Exec                                  3             3           9
         rules with Divisions                                                                                              agreeing Service Lines and   on progress
                                                                                                                           agreeing ground rules


     425 Failure to engage clinicians    4            1            4           4               4      0      0      0 SLR/SLM group tasked with         Report through to F&P Exec                                  4             1           4
                                                                                                                           agreeing Service Lines and   on progress
                                                                                                                           agreeing ground rules


Major Element                                                                                                                                                                                                                                         Lead
                                                                                                                                                                                                                                                                                                                                                 Deadline

4.5      Implement an agreed programme of service improvement projects to deliver improved efficiency across the organisation                                                                                                                         Director of Development                                                                        3/31/2010

                                                                                                        Current
                                                                                                        Totals
ID       Risks                             Initial Risk                                                                             Controls                  Assurances             Reported Assurances           Current Risk Gaps in Controls                                   Gaps in Assurance        Action Plan               Who           When
                                             Rating                                                                                                                                  Identified in Board Reports   Rating JUN
                                                                           Intial (Inherent)




                                                                                                                                                                                     and External Assessments
                                        Consequence




                                                                                                                                                                                                                   Consequence
                                                      Likelihood




                                                                                                                                                                                                                                 Likelihood
                                                                                                                   MARCH
                                                                                               JUNE
                                                                                                      SEPT
                                                                                                             DEC
                                                                   Total




                                                                                                                                                                                                                                              Total
     426 Service Improvement             3            3            9           9               9      0      0      0 Updates to Management Board Management Board                                                  3             3           9       Lack of a clear processes                        Process for prioritising    Project
         Programme doesn't                                                                                                                                                                                                                            to determine the service                         and implementing to be      Manager -
         address priority areas                                                                                                                                                                                                                       improvement programme                            set-up and                  Clinical          9/30/2009
                                                                                                                                                                                                                                                                                                       communicated to             Services
                                                                                                                                                                                                                                                                                                       stakeholders                Improvement


     427 Lack of engagement with         3            3            9           9               9      0      0      0 Agreed programme in place         Management Board                                            3             3           9       Lack of a clear processes                        Process for prioritising    Project
         stakeholders to implement                                                                                                                                                                                                                    to determine the service                         and implementing to be      Manager -
         changes within individual                                                                                                                                                                                                                    improvement programme                            set-up and                  Clinical
         service projects                                                                                                                                                                                                                                                                              communicated to             Services          9/30/2009
                                                                                                                                                                                                                                                                                                       stakeholders                Improvement

                                                                                                                                                                                                                                                      Lack of Project definition                       Ensure Project Initiation   Project            on-going
                                                                                                                                                                                                                                                      at start of projects                             Documents are in place      Manager -
                                                                                                                                                                                                                                                                                                       for all Improvement         Clinical
                                                                                                                                                                                                                                                                                                       Projects                    Services
                                                                                                                                                                                                                                                                                                                                   Improvement




                                                                                                                                                                                     Collated by Pat Morris
                                                                                                                                                                                     Head of Governance                                                                                                                                                     19
             Enclosure Oi                                                                                                                                                                                                                                                                                                        Objective 5

                                                                                                                                                                        Board Assurance Framework 2009-2010




         Principle Objective 5:                                         The Trust will improve the processes that support the Trust's response in the event of a major emergency

         SfBH Domain                                                    Public Health

         Lead Director                                                  Director of Operations & Nursing

5.1      Ensure capacity management and escalation plans are in place and known across the organisation                                                                                                                                         Director of Operations & Nursing                                                     30/09/2009

                                                                                                     Current
                                                                                                     Totals
ID       Risks                          Initial Risk                                                                             Controls                  Assurances         Reported Assurances            Current Risk Gaps in Controls                               Gaps in Assurance        Action Plan             Who         When
                                          Rating                                                                                                                               Identified in Board Reports   Rating JUN
                                                                        Intial (Inherent)




                                                                                                                                                                               and External Assessments
                                     Consequence




                                                                                                                                                                                                             Consequence
                                                   Likelihood




                                                                                                                                                                                                                           Likelihood
                                                                                                                MARCH
                                                                                            JUNE
                                                                                                   SEPT
                                                                                                          DEC
                                                                Total




                                                                                                                                                                                                                                        Total
     428 Health economy escalation    4            4            16      16 16                      0      0      0 Emergency Planning Lead           Management Board                                         4             4           16 Health Economy                                    To liaise with Emergency Director of    31/07/2009
         plans and specific winter                                                                                                                                                                                                              Escalation Plan                              Care Network Director to Operations
         plan are not agreed                                                                                            PCT CEO Chairs Urgent Care   Trust Board                                                                                                                             agree Escalation Plan
                                                                                                                        meeting for Warwickshire
                                                                                                                                                                                                                                                Health Economy Winter
                                                                                                                        Coventry and Warwickshire                                                                                               Plan                                         To liaise with Emergency Director of    30/09/2009
                                                                                                                        Care Board                                                                                                                                                           Care Network Director to Operations
                                                                                                                                                                                                                                                Internal Communication                       agree Winter Plan
                                                                                                                                                                                                                                                Plan

                                                                                                                                                                                                                                                                                             Internal Communication   AGM/           31/10/2009
                                                                                                                                                                                                                                                                                             Plan to be developed     Hospital
                                                                                                                                                                                                                                                                                             and actioned             Manager




                                                                                                                                                                               Collated by Pat Morris
                                                                                                                                                                               Head of Governance                                                                                                                                            20
             Enclosure Oi                                                                                                                                                                                                                                                                                                                  Objective 5

                                                                                                                                                                            Board Assurance Framework 2009-2010




Major Element                                                                                                                                                                                                                                          Lead
                                                                                                                                                                                                                                                                                                                                                  Deadline

5.2      Test and refine plans to manage a pandemic influenza outbreak                                                                                                                                                                                 Director of Operations & Nursing                                                           9/30/2009

                                                                                                      Current
                                                                                                      Totals
ID       Risks                           Initial Risk                                                                              Controls                     Assurances            Reported Assurances           Current Risk Gaps in Controls                                 Gaps in Assurance          Action Plan              Who            When
                                           Rating                        Intial (Inherent)                                                                                            Identified in Board Reports   Rating JUN
                                                                                                                                                                                      and External Assessments
                                      Consequence




                                                                                                                                                                                                                    Consequence
                                                    Likelihood




                                                                                                                                                                                                                                  Likelihood
                                                                                                                 MARCH
                                                                                             JUNE
                                                                                                    SEPT
                                                                                                           DEC
                                                                 Total




                                                                                                                                                                                                                                               Total
     429 The Trust's Pandemic Flu      5            3            15      15 10                      0      0      0 Pandemic Flu Plan which has           Emergency Planning Group                                   5             2           10 Annual Flu plan test not        Awaiting report from   Test Plan                Emergency         30/09/2009
         Plan is not robust enough                                                                                       been Tested in a Tabletop                                                                                                     yet carried out            Decotamination Audit                            Planning Lead
         to support a serious                                                                                            exercise
         epidemic/pandemic of
         much greater severity than                                                                                      Live exercise since April 27th   Mangement Board            Update to Trust Board                                             Annual Regional                                   Action plan to be        Emergency         31/07/2009
         the usual seasonal Flu                                                                                          as a response to Swine Flu                                  28/05/2009                                                        Pandemic Flu audit to be                          developed from Report    Planning Lead
                                                                                                                         Outbreak - learning has been                                                                                                  completed                                         of the Decontamination
                                                                                                                         used to update prepandemic                                                                                                                                                      Unit (A&E) Audit
                                                                                                                         phase section of the plan


                                                                                                                         Flu plan tested with senior      Trust Board
                                                                                                                         managers and clincians
                                                                                                                         Flu Pandemic Plan (Annual)
                                                                                                                         updated and approved by the
                                                                                                                         Trust Emergency Planning
                                                                                                                         Group in April submitted to
                                                                                                                         SHA 09/06/2009
                                                                                                                         Decontamination Unit (A&E)
                                                                                                                         tested by external agency




                                                                                                                                                                                       Collated by Pat Morris
                                                                                                                                                                                       Head of Governance                                                                                                                                                     21
             Enclosure Oi                                                                                                                                                                                                                                                                                                              Objective 5

                                                                                                                                                                           Board Assurance Framework 2009-2010




Major Element                                                                                                                                                                                                                                      Lead
                                                                                                                                                                                                                                                                                                                                              Deadline

5.3      Ensure Business Contnuity palns are in place for all areas of the Trust                                                                                                                                                                   Director of Operations & Nursing                                                             31/02/2010

                                                                                                   Current
                                                                                                   Totals
ID       Risks                        Initial Risk                                                                              Controls                      Assurances         Reported Assurances            Current Risk Gaps in Controls                                   Gaps in Assurance        Action Plan              Who           When
                                        Rating                        Intial (Inherent)                                                                                           Identified in Board Reports   Rating JUN
                                                                                                                                                                                  and External Assessments
                                   Consequence




                                                                                                                                                                                                                Consequence
                                                 Likelihood




                                                                                                                                                                                                                              Likelihood
                                                                                                              MARCH
                                                                                          JUNE
                                                                                                 SEPT
                                                                                                        DEC
                                                              Total




                                                                                                                                                                                                                                           Total
     266 Resource constraints to    3            4            12      12                  9      0      0      0 Part-time planning lead                Risk Management Board                                    3             3           9       Major Incident Plan needs                        Major Incident Plan to be Emergency         31/07/2009
         complete all actions                                                                                                                                                                                                                      updating (Annual                                 updated and approved      Planning Lead
         relating to business                                                                                                                                                                                                                      requirement)                                     by Management Board
                                                                                                                      Business Continuity Strategy      Management Board
         continuity plans, major                                                                                                                                                                                                                                                                    and Trust Board
         incident testing and                                                                                         Business Continuity Training      Trust Board
         training.
                                                                                                                      Major Incident Plan                                                                                                          Remaining Business                               Emergency Planning        Emergency         30/09/2009
                                                                                                                                                                                                                                                   Contiuity Plans (G4S,                            Lead to ensure that all   Planning Lead
                                                                                                                      Emergency Planning Group                                                                                                     Finance)                                         plans are submitted

                                                                                                                      Responsibility of attendance at                                                                                              Major Incident Training to
                                                                                                                      Local Resilience Forum sub-                                                                                                  On-call managers and
                                                                                                                      groups agreed at management                                                                                                  hospital bleep holders
                                                                                                                                                                                                                                                                                                    Emergency Planning to     Emergency         31/03/2010
                                                                                                                      board
                                                                                                                                                                                                                                                                                                    deliver training to       Planning Lead
                                                                                                                      Business Continuity Plans -                                                                                                                                                   appropraite staff
                                                                                                                      90% complete




                                                                                                                                                                                  Collated by Pat Morris
                                                                                                                                                                                  Head of Governance                                                                                                                                                     22
              Enclosure Oi                                                                                                                                                                                                                                                                                     Objective 6

                                                                                                                                                                                    Board Assurance Framework 2009-2010




         Principle Objective 6:                                            The Trust will improve the patient experience within the Trust

         SfBH Domain                                                       Patient Focus, Accessible & Responsive Care

         Lead Director                                                     Director of Operations & Nursing

Major Element                                                                                                                                                                                                                                            Lead
                                                                                                                                                                                                                                                                                                                    Deadline
Major Element                                                                                                                                                                                                                                            Lead
                                                                                                                                                                                                                                                                                                                    Deadline
         Work with the Governors to establish the Terms of Reference and role of the Patients' Forum and clarify processes for input
6.1                                                                                                                                                                                                                                                      Director of Development                                    7/31/2009
         from members
                                                      Current
                                                       Totals
ID       Risks                 Initial Risk                            Controls                 Assurances        Reported Assurances                                                                                 Current Risk Gaps in Controls                         Gaps in Assurance   Action Plan   Who      When
                                 Rating                                                                           Identified in Board Reports                                                                         Rating JUN
                                                                           Intial (Inherent)




                                                                                                                                                                                           and External Assessments
                                        Consequence




                                                                                                                                                                                                                      Consequence
                                                      Likelihood




                                                                                                                                                                                                                                    Likelihood
                                                                                                                   MARCH
                                                                                               JUNE
                                                                                                      SEPT
                                                                                                             DEC
                                                                   Total




                                                                                                                                                                                                                                                 Total
     431 Lack of understanding by        2            3            6           6               6      0      0      0 Paper prepared for early               Governor's Induction                                      2             3           6
         the governors of the role of                                                                                      presentation to Board of          Programme
         the patient forum                                                                                                 Governors

                                                                                                                           Patients' Forum included within
                                                                                                                           Induction programme




                                                                                                                                                                                           Collated by Pat Morris
                                                                                                                                                                                           Head of Governance                                                                                                              23
             Enclosure Oi                                                                                                                                                                                                                                                                                                                               Objective 6

                                                                                                                                                                                  Board Assurance Framework 2009-2010




Major Element                                                                                                                                                                                                                                               Lead
                                                                                                                                                                                                                                                                                                                                                                  Deadline
         Utilise the output from all patient feedback mechanisms to develop patient reported outcome measures (PROMS) as part of the                                                                                                                        Director of Operations & Nursing
6.2                                                                                                                                                                                                                                                                                                                                                               3/31/2010
         Trust's Quality Accounts
                                                        Current
                                                         Totals
ID       Risks                   Initial Risk                            Controls              Assurances      Reported Assurances                                                                                       Current Risk Gaps in Controls                                   Gaps in Assurance               Action Plan                  Who            When
                                    Rating                                Intial (Inherent)                     Identified in Board Reports                                                                              Rating JUN
                                                                                                                                                                                           and External Assessments
                                       Consequence




                                                                                                                                                                                                                         Consequence
                                                     Likelihood




                                                                                                                                                                                                                                       Likelihood
                                                                                                                  MARCH
                                                                                              JUNE
                                                                                                     SEPT
                                                                                                            DEC
                                                                  Total




                                                                                                                                                                                                                                                    Total
     432 Insufficent feedback from      3            3            9           9               9      0      0      0 Personal Objective for                 Patient Experience Group                                      3             3           9       Personal Objective for all                             Matrons to ensure that the Associate              31/03/2009
         patients on bedside TV's to                                                                                      Associate Director of Nursing     will review data monthly and                                                                    Ward Managers                                          objective is included in all Director for
         be of statistical                                                                                                                                  report to Board quarterly                                                                                                                              ward manager appraisals Nursing
         significance for use in the
         Quality Accounts                                                                                                                                   Data Item on monthly Trust                                                                      Communication Plan                                     Develop and implement a      Communication        30/06/2009
                                                                                                                                                            Board Performance Report                                                                                                                               communication plan           Manager



     433 Failure to meet 80% return     3            4            12      12 12                      0      0      0 Weekly monitoring of                                                                                 3             4           12 Survey Process not                Reporting mechanism for   Process for administering 18wks manager           31/07/2009
         rate for National Proms                                                                                          completion rates by 18wks                                                                                                         designed to relably meet     Assurance                 surveys and ensuring
         survey for surgical                                                                                              manager                                                                                                                           the 80% completion                                     completion rate met needs
         pathways                                                                                                                                                                                                                                                                                                  improvement
                                                                                                                          18 weeks Manager

                                                                                                                                                                                                                                                                                                                   Reporting mechanism for      18wks manager         6/30/2009
                                                                                                                                                                                                                                                                                                                   Assurance to be identied
                                                                                                                                                                                                                                                                                                                   and enacted


Major Element                                                                                                                                                                                                                                               Lead
                                                                                                                                                                                                                                                                                                                                                                  Deadline

6.3      Ensure patient representation on all major development projects                                                                                                                                                                                    Director of Development                                                                               Ongoing

                                                                                                       Current
                                                                                                       Totals
ID       Risks                            Initial Risk                                                                              Controls                      Assurances               Reported Assurances           Current Risk Gaps in Controls                                   Gaps in Assurance               Action Plan                  Who            When
                                            Rating                                                                                                                                         Identified in Board Reports   Rating JUN
                                                                          Intial (Inherent)




                                                                                                                                                                                           and External Assessments
                                       Consequence




                                                                                                                                                                                                                         Consequence
                                                     Likelihood




                                                                                                                                                                                                                                       Likelihood
                                                                                                                  MARCH
                                                                                              JUNE
                                                                                                     SEPT
                                                                                                            DEC
                                                                  Total




                                                                                                                                                                                                                                                    Total
     434 Lack of available and          3            3            9           9               6      0      0      0 Patients' Forum                        Project Team Minutes                                          3             2           6       Lack of broader                                        Include Governor input in    Trust Secretary      31/07/2009
         appropraite patient                                                                                              representatives included within                                                                                                   perspective from public                                major schemes
         representation                                                                                                   current projects
                                                                                                                                                            Highlight report to
                                                                                                                                                            Management Board




                                                                                                                                                                                            Collated by Pat Morris
                                                                                                                                                                                            Head of Governance                                                                                                                                                           24
              Enclosure Oi                                                                                                                                                                                                                                                                                                                  Objective 6

                                                                                                                                                                              Board Assurance Framework 2009-2010




Major Element                                                                                                                                                                                                                                           Lead
                                                                                                                                                                                                                                                                                                                                                      Deadline

6.4      Improve Trust performance on single sex accommodation                                                                                                                                                                                          Director of Operations & Nursing                                                              12/31/2009

                                                                                                     Current
                                                                                                     Totals
ID       Risks                          Initial Risk                                                                               Controls                    Assurances              Reported Assurances           Current Risk Gaps in Controls                                   Gaps in Assurance         Action Plan               Who             When
                                          Rating                        Intial (Inherent)                                                                                              Identified in Board Reports   Rating JUN
                                                                                                                                                                                       and External Assessments
                                     Consequence




                                                                                                                                                                                                                     Consequence
                                                   Likelihood




                                                                                                                                                                                                                                   Likelihood
                                                                                                                MARCH
                                                                                            JUNE
                                                                                                   SEPT
                                                                                                          DEC
                                                                Total




                                                                                                                                                                                                                                                Total
     435 Trusts occupancy is too      3            4            12      12                  9      0      0      0 New medical process                  Monthly report to Patient     Patient Experience Group        3             3           9       Enough bed capacity                              Additional ward            Director of          11/30/2009
         high to enable single sex                                                                                                                      Experience Group              (21/04, 19/05, 16/06)                                                                                              construction               Development
         provision
                                                                                                                        Matron's follow up mixed sex    Annual privacy and dignity                                                                      Policy for managing single                       Single-sex policy to be    Associate             7/31/2009
                                                                                                                        report                          audit                                                                                           sex accomadation                                 approved by Trust Board    Director of
                                                                                                                                                                                                                                                                                                                                    Nursing
                                                                                                                        Patient transfer procedure      Matron's snapshot audits                                                                        Bed Management Policy                            Bed management             GM for Medicine      30/06/2009
                                                                                                                                                                                                                                                        out-of date                                      procedure and guidelines
                                                                                                                                                                                                                                                                                                         reviewed and updated to
                                                                                                                        CQUIN                           PPI audits
                                                                                                                                                                                                                                                                                                         Management Board for
                                                                                                                        Essence of care benchmarking Quality Review meeting with                                                                                                                         approval
                                                                                                                                                     PCT
                                                                                                                        Dignity in care campaign
                                                                                                                        Dignity toolkit
                                                                                                                        Daily monitoring of mixed sex
                                                                                                                        bays


Major Element                                                                                                                                                                                                                                           Lead
                                                                                                                                                                                                                                                                                                                                                      Deadline
                                                                                                                                                                                                                                                        Director of Operations & Nursing
6.5      Provide strong leadership within the Trust to implement processes that improve the patient experience                                                                                                                                                                                                                                        6/30/2009

                                                                                                     Current
                                                                                                     Totals
ID       Risks                          Initial Risk                                                                               Controls                    Assurances              Reported Assurances           Current Risk Gaps in Controls                                   Gaps in Assurance         Action Plan               Who             When
                                          Rating                                                                                                                                       Identified in Board Reports   Rating JUN
                                                                        Intial (Inherent)




                                                                                                                                                                                       and External Assessments
                                     Consequence




                                                                                                                                                                                                                     Consequence
                                                   Likelihood




                                                                                                                                                                                                                                   Likelihood
                                                                                                                MARCH
                                                                                            JUNE
                                                                                                   SEPT
                                                                                                          DEC
                                                                Total




                                                                                                                                                                                                                                                Total
     436 Nursing and medical staff    3            3            9           9               9      0      0      0 Regular staff meetings within        Complaints                                                    3             3           9
         do not support A&E                                                                                             the department
         manager to implement new
         processes and follow                                                                                           Communication framework for     Patient satisfaction and
         through on action plans                                                                                        dissemination of information    feedback

                                                                                                                        Appraisals for all staff        Clinical incident reporting
                                                                                                                                                        Annual patient survey
                                                                                                                                                        Patient experience report
                                                                                                                                                        Clinical Governance
                                                                                                                                                        Committee
                                                                                                                                                        Trust Board




                                                                                                                                                                                        Collated by Pat Morris
                                                                                                                                                                                        Head of Governance                                                                                                                                                   25
              Enclosure Oi                                                                                                                                                                                                                                                                                                               Objective 6

                                                                                                                                                                           Board Assurance Framework 2009-2010




                                                                                                      Current
                                                                                                      Totals
ID       Risks                           Initial Risk                                                                              Controls                   Assurances            Reported Assurances           Current Risk Gaps in Controls                                    Gaps in Assurance        Action Plan               Who          When
                                           Rating                                                                                                                                   Identified in Board Reports   Rating JUN




                                                                         Intial (Inherent)
                                                                                                                                                                                    and External Assessments
                                      Consequence




                                                                                                                                                                                                                  Consequence
                                                    Likelihood




                                                                                                                                                                                                                                    Likelihood
                                                                                                                 MARCH
                                                                                             JUNE
                                                                                                    SEPT
                                                                                                           DEC
                                                                 Total




                                                                                                                                                                                                                                                   Total
     437 Leadership skills are not     3            4            12      12 12                      0      0      0 Learning beyond Registration        Patient Experience Group                                                3                4 12 Management                                       To develop set of         Associate         12/31/2009
         consistent across the                                                                                           training plan                                                                                                                     Competencies                                competencies and          Director for
         organisation which effects                                                                                      Leadership Charter             Senior Nurses meeting                                                                              Development Programme                       development programme     Nursing
         the patient experience                                                                                                                                                                                                                                                                        to meet identfied needs
                                                                                                                         Trained personal and team       Learning Group
                                                                                                                         coaches within the organisation

                                                                                                                         Mentoring of Ward Managers




Major Element                                                                                                                                                                                                                                              Lead
                                                                                                                                                                                                                                                                                                                                                Deadline

6.6      Provide a Pharmacy facility close to Outpatients                                                                                                                                                                                                  Director of Development                                                              9/30/2009

                                                                                                      Current
                                                                                                      Totals
ID       Risks                           Initial Risk                                                                              Controls                   Assurances            Reported Assurances           Current Risk Gaps in Controls                                    Gaps in Assurance        Action Plan               Who          When
                                           Rating                                                                                                                                   Identified in Board Reports   Rating JUN
                                                                         Intial (Inherent)




                                                                                                                                                                                    and External Assessments
                                      Consequence




                                                                                                                                                                                                                  Consequence
                                                    Likelihood




                                                                                                                                                                                                                                    Likelihood
                                                                                                                 MARCH
                                                                                             JUNE
                                                                                                    SEPT
                                                                                                           DEC
                                                                 Total




                                                                                                                                                                                                                                                   Total
     275 The Trust is unable to        4            3            12      12 12                      0      0      0 Project Team                        Monthly Capital Committee                                  4                 3             12 Building project not yet                         New Pharmacy to be        Director of        7/31/2009
         provide easier access to                                                                                                                       Meeting                                                                                            complete                                    opened                    Development
         Pharamcy Servces for Out-                                                                                       Project Plan
         Patients                                                                                                        Capital Plan                   Bi-monthly Management
                                                                                                                                                        Board meeting




                                                                                                                                                                                     Collated by Pat Morris
                                                                                                                                                                                     Head of Governance                                                                                                                                                26
             Enclosure Oi                                                                                                                                                                                                                                                                                                Objective 6

                                                                                                                                                       Board Assurance Framework 2009-2010




Major Element                                                                                                                                                                                                                  Lead
                                                                                                                                                                                                                                                                                                                                     Deadline

6.7      Review car parking pricing policy to ensure prices are fair from a user perspective                                                                                                                                   Director fo Finance                                                                                   8/31/2009

                                                                                                     Current
                                                                                                     Totals
ID       Risks                          Initial Risk                                                                         Controls         Assurances     Reported Assurances            Current Risk Gaps in Controls                                  Gaps in Assurance               Action Plan                 Who              When
                                          Rating                        Intial (Inherent)                                                                     Identified in Board Reports   Rating JUN
                                                                                                                                                              and External Assessments
                                     Consequence




                                                                                                                                                                                            Consequence
                                                   Likelihood




                                                                                                                                                                                                          Likelihood
                                                                                                                MARCH
                                                                                            JUNE
                                                                                                   SEPT
                                                                                                          DEC
                                                                Total




                                                                                                                                                                                                                       Total
     439 Revised pricing policy       4            3            12      12 12                      0      0      0 Present Policy       Trust Board                                          4             3           12 Agreement with patient           Trust Board reports       To meet with patient       Finance Director        31/08/2009
         unacceptable to staff and                                                                                                                                                                                             groups and shadow           acceptance of revised     groups and shadow
         public                                                                                                                                                                                                                governors                   charges from staff side   governors to dscuss public
                                                                                                                                                                                                                                                           and public                charging changes to get
                                                                                                                                                                                                                                                                                     agreement.
                                                                                                                                                                                                                               Agreement with staff side                             To meet with Staff Side to   Finance Director      31/08/2009
                                                                                                                                                                                                                                                                                     discuss staffing charging
                                                                                                                                                                                                                                                                                     policy (Staffing Charging
                                                                                                                                                                                                                                                                                     Policy to go hand in hand
                                                                                                                                                                                                                                                                                     with green issues)



     440 Revised pricing policy       4            2            8           8               8      0      0      0 Present Policy       Trust Board                                          4             2           8       Revised Pricing Policy      Board approval            Policy to be revised to      Finance Director      31/08/2009
         causes loss of income and                                                                                                                                                                                                                                                   cover additional car
         additional costs                                                                                                                                                                                                                                                            parking costs to minimise
                                                                                                                                                                                                                                                                                     additional costs to Trust



                                                                                                                                                                                                                                                                                     Paper on options to be       Finance Director      31/08/2009
                                                                                                                                                                                                                                                                                     presented and subject to
                                                                                                                                                                                                                                                                                     Board approval




                                                                                                                                                              Collated by Pat Morris
                                                                                                                                                              Head of Governance                                                                                                                                                            27
             Enclosure Oi                                                                                                                                                                                                                                                                                           Objective 7

                                                                                                                                                                                 Board Assurance Framework 2009-2010




         Principle Objective 7:                                           The Trust will improve staff satisfaction across the organisation

         SfBH Domain                                                      Governance

         Lead Director                                                    Director of Operations & Nursing

Major Element                                                                                                                                                                                                                                                Lead
                                                                                                                                                                                                                                                                                                                        Deadline

7.1      Develop and implement an action plan following staff engagement sessions and staff survey                                                                                                                                                           Director of Human Resources                                On-going

                                                                                                       Current
                                                                                                       Totals
ID       Risks                            Initial Risk                                                                               Controls                      Assurances              Reported Assurances            Current Risk Gaps in Controls                         Gaps in Assurance   Action Plan   Who     When
                                            Rating                                                                                                                                          Identified in Board Reports   Rating JUN
                                                                          Intial (Inherent)




                                                                                                                                                                                            and External Assessments
                                       Consequence




                                                                                                                                                                                                                          Consequence
                                                     Likelihood




                                                                                                                                                                                                                                        Likelihood
                                                                                                                  MARCH
                                                                                              JUNE
                                                                                                     SEPT
                                                                                                            DEC
                                                                  Total




                                                                                                                                                                                                                                                     Total
     445 Managers and Staff do not      3            4            12      12                  9      0      0      0 Well-being Steering Group               Appraisal performance to     Executive F&P meeting            3             3           9
         engage adequately to                                                                                                                                Executive F&P                (26/05/2009) reported that
         support delivery of actions                                                                                      Staff egagement working                                         undertaking of appraisal in
         outlined in the action plan                                                                                      groups                                                          Surgery had improved
                                                                                                                          Objectives set in Appraisals       Staff Survey

                                                                                                                          Communication through E-           Monitoring of Action Plans
                                                                                                                          Pulse and Team Brief               for the Staff Survey and
                                                                                                                                                             Staff Engagement
                                                                                                                          Staff Survey Action Plan
                                                                                                                          Staff Engagement Plan



     279 Staff do not receive an        3            3            9           9               6      0      0      0 Cascade of an objective to            Feedback route through the Executive F&P meeting                3             2           6
         annual appraisal                                                                                                 achieve appraisal for all staff  management structure       (26/05/2009) reported that
                                                                                                                          Role identified and recruited to Quarterly monitoring in HR undertaking of appraisal in
                                                                                                                          support delivery of appraisal    outcome reported to Trust  Surgery had improved
                                                                                                                          and KSF at department level      Board

                                                                                                                          Reviewed and simplified KSF        National Staff Survey
                                                                                                                          and appraisal paperwork
                                                                                                                          Ongoing Reviewer and
                                                                                                                          Reviewing Training
                                                                                                                          Fortnightly contact with
                                                                                                                          managers to check that
                                                                                                                          schedule appraisals take place

                                                                                                                          Appraisal facilitator supporting
                                                                                                                          managers to embed KSF and
                                                                                                                          Appraisal




                                                                                                                                                                                            Collated by Pat Morris
                                                                                                                                                                                            Head of Governance                                                                                                                     28
              Enclosure Oi                                                                                                                                                                                                                                                                                                                            Objective 7

                                                                                                                                                                           Board Assurance Framework 2009-2010




Major Element                                                                                                                                                                                                                                          Lead
                                                                                                                                                                                                                                                                                                                                                              Deadline

7.2       Ensure all staff receive key messages by improving general communications including e-Pulse and a quarterly Pulse magazine                                                                                                                   Director of Human Resources                                                                            6/30/2009

                                                                                                       Current
                                                                                                       Totals
ID        Risks                           Initial Risk                                                                             Controls                    Assurances             Reported Assurances           Current Risk Gaps in Controls                                     Gaps in Assurance                Action Plan               Who             When
                                            Rating                                                                                                                                    Identified in Board Reports   Rating JUN
                                                                          Intial (Inherent)
                                                                                                                                                                                      and External Assessments
                                       Consequence




                                                                                                                                                                                                                    Consequence
                                                     Likelihood




                                                                                                                                                                                                                                  Likelihood
                                                                                                                  MARCH
                                                                                              JUNE
                                                                                                     SEPT
                                                                                                            DEC
                                                                  Total




                                                                                                                                                                                                                                               Total
     446 Executives and Senior          4            3            12      12 12                      0      0      0 Communications Manager to          Management Board                                             4             3           12 Dependent objective                 No process for monitoring   Trust Key Objectives      Director of HR      30/09/2009
         Managers do not                                                                                                  attend Executive Team Brief                                                                                                  continuing to be a high        that Trust Key Objectives   relating to
         participate in identifying                                                                                       monthly                       Learning Group                                                                                 priority as it is cascaded     are cascaded though the     communication to be
         key messages                                                                                                                                                                                                                                  through the Trust              organisation                implemented for all
                                                                                                                                                                                                                                                                                                                  managers
                                                                                                                                                                                                                                                       Not all managers have                                      Monitoring form to be     Director of HR      30/09/2009
                                                                                                                                                                                                                                                       well-developed leadership                                  devised to provide
                                                                                                                                                                                                                                                       skills                                                     assurance that key
                                                                                                                                                                                                                                                                                                                  objectives are being
                                                                                                                                                                                                                                                                                                                  written into managers
                                                                                                                                                                                                                                                                                                                  perfomance objectives

                                                                                                                                                                                                                                                                                                                  Agree and implement       Director of HR      30/09/2009
                                                                                                                                                                                                                                                                                                                  Leadership
                                                                                                                                                                                                                                                                                                                  Competences



Major Element                                                                                                                                                                                                                                          Lead
                                                                                                                                                                                                                                                                                                                                                              Deadline

7.3       Improve Intranet layout and content so that staff find it easy to use                                                                                                                                                                        Director of Human Resources                                                                            11/30/2009

                                                                                                       Current
                                                                                                       Totals
ID        Risks                           Initial Risk                                                                             Controls                    Assurances             Reported Assurances           Current Risk Gaps in Controls                                     Gaps in Assurance                Action Plan               Who             When
                                            Rating                                                                                                                                    Identified in Board Reports   Rating JUN
                                                                          Intial (Inherent)




                                                                                                                                                                                      and External Assessments
                                       Consequence




                                                                                                                                                                                                                    Consequence
                                                     Likelihood




                                                                                                                                                                                                                                  Likelihood
                                                                                                                  MARCH
                                                                                              JUNE
                                                                                                     SEPT
                                                                                                            DEC
                                                                  Total




                                                                                                                                                                                                                                               Total
     447 Insufficent IT staffing        2            4            8           8               8      0      0      0 Prioritise process for accessing Management Board minutes                                       2             4           8       Training of staff outside of                               Improve technical design Associate            30/09/2009
         resource to design, deliver                                                                                      Shared Services               - quarterly                                                                                    Shared Services to                                         of the Trust website to  Director for IT
         changes and maintain the                                                                                                                                                                                                                      maintain content                                           enable non-technical
         site content                                                                                                                                   Trust IT Committtee minutes                                                                                                                               administrator to update
                                                                                                                                                                                                                                                                                                                  content
                                                                                                                                                                                                                                                       Easy to use structure of
                                                                                                                                                                                                                                                       Website for non-technical
                                                                                                                                                                                                                                                       administrators                                             Administrators to be      Associate           30/11/2009
                                                                                                                                                                                                                                                                                                                  trained in updating       Director for IT
          Risk same as 10.2                                                                                                                                                                                                                                                                                       website




                                                                                                                                                                                      Collated by Pat Morris
                                                                                                                                                                                      Head of Governance                                                                                                                                                                   29
              Enclosure Oi                                                                                                                                                                                                                                                                                                                    Objective 7

                                                                                                                                                                                   Board Assurance Framework 2009-2010




Major Element                                                                                                                                                                                                                                                  Lead
                                                                                                                                                                                                                                                                                                                                                 Deadline

7.4       Provide improved facilities for staff working in the hospital night                                                                                                                                                                                  Director of Development                                                           12/31/2009

                                                                                                         Current
                                                                                                         Totals
ID        Risks                             Initial Risk                                                                              Controls                       Assurances              Reported Assurances            Current Risk Gaps in Controls                                 Gaps in Assurance       Action Plan          Who          When
                                              Rating                                                                                                                                          Identified in Board Reports   Rating JUN
                                                                            Intial (Inherent)
                                                                                                                                                                                              and External Assessments
                                         Consequence




                                                                                                                                                                                                                            Consequence
                                                       Likelihood




                                                                                                                                                                                                                                          Likelihood
                                                                                                                    MARCH
                                                                                                JUNE
                                                                                                       SEPT
                                                                                                              DEC
                                                                    Total




                                                                                                                                                                                                                                                       Total
     448 Lack of clarity regarding        3            3            9           9               6      0      0      0 Hospital at Night                       Update on success of          Trust Board                     2             3           6       Lack of understanding of                       Requirements to be   Director of     31/12/2009
         requirements                                                                                                       accommodation provided             Hospital at Night reported at                                                                   further requirements                           determined           Development
                                                                                                                            within refurbished Dr's mess       management Board and
                                                                                                                                                               Trust Board
                                                                                                                                                                                            Management Board


Major Element                                                                                                                                                                                                                                                  Lead
                                                                                                                                                                                                                                                                                                                                                 Deadline
          Improve staff recruitment and retention in specific areas of the Trust e.g Medical Assessment Unit, Theatres, whilst maintaining
7.5                                                                                                                                                        Director of Human Resources                                                                                                                                                           9/30/2009
          the quality of care provided in other areas of the Trust
                                                           Current
                                                           Totals
ID        Risks                    Initial Risk                             Controls              Assurances        Reported Assurances Current Risk Gaps in Controls         Gaps in Assurance                                                                                                                   Action Plan          Who          When
                                     Rating                                                                         Identified in Board Reports Rating JUN
                                                                            Intial (Inherent)




                                                                                                                                                                                              and External Assessments
                                         Consequence




                                                                                                                                                                                                                            Consequence
                                                       Likelihood




                                                                                                                                                                                                                                          Likelihood
                                                                                                                    MARCH
                                                                                                JUNE
                                                                                                       SEPT
                                                                                                              DEC
                                                                    Total




                                                                                                                                                                                                                                                       Total
     449 The Trust is unable to           5            3            15      15 15                      0      0      0 Recruitment group established Quarterly Workforce Report                                              5             3           15 Nusing Bank not                                     Nurse bank mangement General         30/09/2009
         recruit new staff with                                                                                                                                to Trust Board                                                                                  responding to need                             and administrative   Manager
         appropriate competences                                                                                            Ongoing recruitment                Recruitment monitoring                                                                                                                         support to be        Medicine
                                                                                                                                                               through Executive F&P                                                                                                                          strengthened

                                                                                                                            Working with local university to
                                                                                                                            attract newly qualified staff



     450 The Trust is unable to           5            3            15      15 15                      0      0      0 Exit Interviews                         Quarterly Workforce Report                                    5             3           15 Nursing Resource                                    Nurse bank mangement General         30/09/2009
         retain staff with appropriate                                                                                                                         to Trust Board                                                                                  Manager not yet                                and administrative   Manager
         competences                                                                                                        Healthcare assistant               Recruitment monitoring                                                                          appointed                                      support to be        Medicine
                                                                                                                            development programme              through Executive F&P                                                                                                                          strengthened
                                                                                                                            Preceptorship support posts                                                                                                        Nusing Bank not
                                                                                                                                                                                                                                                               responding to need
                                                                                                                            Access to learning and
                                                                                                                            development opportunities




                                                                                                                                                                                              Collated by Pat Morris
                                                                                                                                                                                              Head of Governance                                                                                                                                              30
           Enclosure Oi                                                                                                                                                                                                                                                                                                                             Objective 7

                                                                                                                                                                             Board Assurance Framework 2009-2010




Risks carried forward from BAF 2008/9 relevant to Priniciple Objective 7
                                                    Current
                                                     Totals
ID    Risks                 Initial Risk                               Controls                                                                                 Assurances            Reported Assurances           Current Risk Gaps in Controls                                            Gaps in Assurance       Action Plan               Who          When
                              Rating                                                                                                                                                  Identified in Board Reports   Rating JUN



                                                                       Intial (Inherent)
                                                                                                                                                                                      and External Assessments
                                    Consequence




                                                                                                                                                                                                                    Consequence
                                                  Likelihood




                                                                                                                                                                                                                                      Likelihood
                                                                                                               MARCH
                                                                                           JUNE
                                                                                                  SEPT
                                                                                                         DEC
                                                               Total




                                                                                                                                                                                                                                                       Total
  281 Electronic Staff Record        4            3            12      12                  6      0      0      0 Pilot in Therapies, Finance, IT The ability to report training                                                  2                3   6       Manager Briefings                                 Programme of briefing to Director of HR    3/31/2009
      Manager Self-Serve is not                                                                                        and HR                             and appraisal through ESR                                                                                                                              be developed and
      rolled out in line with the                                                                                                                                                                                                                                                                                implemented
      plan                                                                                                             Training of Managers in pilot                                                                                                           Training of all Managers                          Programme of Training    Director of HR    3/31/2009
                                                                                                                       areas in preparation of                                                                                                                 in preparation for roll-out                       to be developed and
                                                                                                                       implementation                                                                                                                          across the Trust in 09/10                         implemented

                                                                                                                       HR has populated Oracle            Monitoring by Learning                                                                               Software incompatible                             Implement solution       Associate         3/31/2009
                                                                                                                       Learning Management for all        Group                                                                                                with PAS                                                                   Director for IT
                                                                                                                       areas
                                                                                                                       ESR Project Board                  Minutes of ESR Project                                                                               Training of all Managers
                                                                                                                                                          Board
                                                                                                                       ESR Newsletter circulated to all                                                                                                        Insufficient HR and IT                            Training of all Managers Director of HR    3/31/2009
                                                                                                                       staff                                                                                                                                   resource to support full                          in preparation for roll-out
                                                                                                                                                                                                                                                               implemention                                      across the Trust. HR to
                                                                                                                                                                                                                                                                                                                 complete work on
                                                                                                                                                                                                                                                                                                                 structures within ESR in
                                                                                                                                                                                                                                                                                                                 preparation.




                                                                                                                                                                                      Collated by Pat Morris
                                                                                                                                                                                      Head of Governance                                                                                                                                                           31
               Enclosure Oi                                                                                                                                                                                                                                                                                                                             Objective 8

                                                                                                                                                                                 Board Assurance Framework 2009-2010




          Principle Objective 8:                                             The Trust will improve close working relationship with PCT and GPs

          SfBH Domain                                                        Public Health: Accessible & Responsive Care

          Lead Director                                                      Director of Development

Major Element                                                                                                                                                                                                                                              Lead
                                                                                                                                                                                                                                                                                                                                                              Deadline

8.1       Provide regular communication directly to GP's through newsletters and Practice meetings                                                                                                                                                         Director of Development                                                                            On-going

                                                                                                          Current
                                                                                                          Totals
ID        Risks                              Initial Risk                                                                              Controls                     Assurances           Reported Assurances            Current Risk Gaps in Controls                                  Gaps in Assurance                 Action Plan               Who           When
                                               Rating                                                                                                                                     Identified in Board Reports   Rating JUN
                                                                             Intial (Inherent)




                                                                                                                                                                                          and External Assessments
                                          Consequence




                                                                                                                                                                                                                        Consequence
                                                        Likelihood




                                                                                                                                                                                                                                      Likelihood
                                                                                                                     MARCH
                                                                                                 JUNE
                                                                                                        SEPT
                                                                                                               DEC
                                                                     Total




                                                                                                                                                                                                                                                   Total
     441 Availability of clinical staff    3            3            9           9               9      0      0      0                                                                                                  3             3           9       Lack of clear programme                                  Marketing Plan to be    Director of           8/31/2009
         for practice meetings                                                                                                                                                                                                                             for visits                                               updated and to included Development
                                                                                                                                                                                                                                                                                                                    schedule of visits



Major Element                                                                                                                                                                                                                                              Lead
                                                                                                                                                                                                                                                                                                                                                              Deadline
          Actively participate in the PCT's rolling programme of service reviews, prepare business cases to identify areas where the Trust
8.2                                                                                                                                                         Director of Development                                                                                                                                                                           On-going
          wishes to bid and prepare tenders ready for submission
                                                          Current
                                                           Totals
ID        Risks                    Initial Risk                             Controls             Assurances         Reported Assurances Current Risk Gaps in Controls           Gaps in Assurance                                                                                                                        Action Plan               Who           When
                                     Rating                                                                          Identified in Board Reports Rating JUN
                                                                             Intial (Inherent)




                                                                                                                                                                                          and External Assessments
                                          Consequence




                                                                                                                                                                                                                        Consequence
                                                        Likelihood




                                                                                                                                                                                                                                      Likelihood
                                                                                                                     MARCH
                                                                                                 JUNE
                                                                                                        SEPT
                                                                                                               DEC
                                                                     Total




                                                                                                                                                                                                                                                   Total
     442 Miss changes to the PCT's         4            2            8           8               8      0      0      0 Monitoring process in place                                                                      4             2           8                                   No notification process in   Obtain clarity from PCT     Project           7/31/2009
         rolling programme because                                                                                                                                                                                                                                                     place with PCT               on this years key           Manager -
         it is changed frequently                                                                                            Clinical reference Group                                                                                                                                                               elements                    Clinical
         and ad hoc                                                                                                          meetings monthly                                                                                                                                                                                                   Services
                                                                                                                                                                                                                                                                                                                                                Improvement
     443 Insufficient notice to            4            3            12      12 12                      0      0      0 Business case process in              Business cases presented   Management Board                4             3           12 Lack of clarity on PCT                                        Obtain clarity from PCT     Project           7/31/2009
         prepare business cases for                                                                                          place                            to Management Board                                                                          plans for tendering                                      on this years key           Manager -
         Trust approval prior to PCT                                                                                                                                                                                                                                                                                elements                    Clinical
         Tendering dead-line                                                                                                                                                                                                                                                                                                                    Services
                                                                                                                                                                                                                                                                                                                                                Improvement
                                                                                                                             Specialty Business Plans                                                                                                      No process for refreshing                                Implement a process         Project           9/30/2009
                                                                                                                             identify key areas of proposed                                                                                                Business plans                                           that is integrated within   Manager -
                                                                                                                             development                                                                                                                                                                            the Trust's business        Clinical
                                                                                                                                                                                                                                                                                                                    planning process            Services
                                                                                                                                                                                                                                                                                                                                                Improvement




                                                                                                                                                                                           Collated by Pat Morris
                                                                                                                                                                                           Head of Governance                                                                                                                                                            32
              Enclosure Oi                                                                                                                                                                                                                                                                                                             Objective 8

                                                                                                                                                                         Board Assurance Framework 2009-2010




ID       Risks                           Initial Risk                                                                             Controls                 Assurances          Reported Assurances            Current Risk Gaps in Controls                                   Gaps in Assurance            Action Plan            Who           When
                                           Rating                                                                                                                               Identified in Board Reports   Rating JUN




                                                                         Intial (Inherent)
                                      Consequence                                                                                                                               and External Assessments




                                                                                                                                                                                                              Consequence
                                                    Likelihood




                                                                                                                                                                                                                            Likelihood
                                                                                                                 MARCH
                                                                                             JUNE
                                                                                                    SEPT
                                                                                                           DEC
                                                                 Total




                                                                                                                                                                                                                                         Total
     444 Lack of expertise for         4            3            12      12                  8      0      0      0 Training of one key member of Improved quality and        Capital Committee                4            2            8       Limited number of staff                              Determine roll out of   Project             9/30/2009
         preparing quality tenders                                                                                       staff                       success of recent bids                                                                      with skills                                          training to other       Manager -
                                                                                                                                                                                                                                                                                                      departments             Clinical
                                                                                                                                                                                                                                                                                                                              Services
                                                                                                                                                                                                                                                                                                                              Improvement



Major Element                                                                                                                                                                                                                                    Lead
                                                                                                                                                                                                                                                                                                                                             Deadline

8.3      Work with GPs to identify services that could be developed to improve local access for patients                                                                                                                                         Director of Development                                                                     On-going

                                                                                                      Current
                                                                                                      Totals
ID       Risks                           Initial Risk                                                                             Controls                 Assurances          Reported Assurances            Current Risk Gaps in Controls                                   Gaps in Assurance            Action Plan            Who           When
                                           Rating                                                                                                                               Identified in Board Reports   Rating JUN
                                                                         Intial (Inherent)




                                                                                                                                                                                and External Assessments
                                      Consequence




                                                                                                                                                                                                              Consequence
                                                    Likelihood




                                                                                                                                                                                                                            Likelihood
                                                                                                                 MARCH
                                                                                             JUNE
                                                                                                    SEPT
                                                                                                           DEC
                                                                 Total




                                                                                                                                                                                                                                         Total
     284 Unable to develop services    3            3            9           9               9      0      0      0 GP Meetings                      Management Board                                          3             3           9       Trust Strategy relating to   Reporting mechanisms for Trust Strategy to be    Director of       30/09/2009
         in the community because                                                                                                                                                                                                                Community Services           dissemination of outcomes updated to reflect     Development
         of lack of support from                                                                                         PCT Plans                                                                                                               needs updating               from CRG unclear          proposed changes to
         PCT/GP or lack of                                                                                               Service Development Plans                                                                                                                                                      Community Services as
         accomodation or lack of                                                                                                                                                                                                                                                                        being suggested by PCT
                                                                                                                         Clinical Reference Group
         resources                                                                                                                                                                                                                                                                                      and report to Board
                                                                                                                         (CRG) meetings

                                                                                                                         Active involvement in PCT                                                                                                                                                    Reporting Mechanisim    Director of        31/07/2009
                                                                                                                         Programme- Transforming                                                                                                                                                      for CRG to be agreed    Development
                                                                                                                         Community Services
         Also on 2.5




                                                                                                                                                                                 Collated by Pat Morris
                                                                                                                                                                                 Head of Governance                                                                                                                                                     33
             Enclosure Oi                                                                                                                                                                                                                                                                                                                 Objective 9

                                                                                                                                                                      Board Assurance Framework 2009-2010




         Principle Objective 9:                                           Improve Patient Safety

         SfBH Domain                                                      Safety

         Lead Director                                                    Medical Director

Major Element                                                                                                                                                                                                                                 Lead
                                                                                                                                                                                                                                                                                                                                                   Deadline

9.1      Develop a set of measures that will form the basis of the Trust's Quality Accounts                                                                                                                                                   Medical Director                                                                                     3/31/2010

                                                                                                       Current
                                                                                                       Totals
ID       Risks                            Initial Risk                                                                              Controls                 Assurances     Reported Assurances            Current Risk Gaps in Controls                                  Gaps in Assurance               Action Plan                 Who             When
                                            Rating                                                                                                                           Identified in Board Reports   Rating JUN
                                                                          Intial (Inherent)




                                                                                                                                                                             and External Assessments
                                       Consequence




                                                                                                                                                                                                           Consequence
                                                     Likelihood




                                                                                                                                                                                                                         Likelihood
                                                                                                                  MARCH
                                                                                              JUNE
                                                                                                     SEPT
                                                                                                            DEC
                                                                  Total




                                                                                                                                                                                                                                      Total
     453 Multiple contributors may      3            3            9           9               9      0      0      0 Meetings with relevelent senior                                                        3             3           9       Lack of clarity regarding   Reporting structure not yet Discuss at Cquinn         Medical Director        ongoing
         obscure the aims of Quality                                                                                      management personel to                                                                                              content (no national        agreed                      meeting to gain PCT
         Accounts                                                                                                         determine focus of accounts                                                                                         excepted parameters)                                    input


                                                                                                                          Attendance at national                                                                                                                                                     Input from Consultants                             ongoing
                                                                                                                          meetings                                                                                                                                                                   via MAOGG and
                                                                                                                          Involvement of PCT through                                                                                                                                                 SAOGG
                                                                                                                          Cquinn discussions
                                                                                                                                                                                                                                                                                                     Input for Patient Safety                           ongoing
                                                                                                                          Involvement of senior clinicinas                                                                                                                                           Group
                                                                                                                                                                                                                                                                                                     Discuss with executive                          31/08/2009
                                                                                                                          through MAOGG & SAOGG                                                                                                                                                      team the reporting
                                                                                                                                                                                                                                                                                                     mechanism for progress
                                                                                                                                                                                                                                                                                                     against the delivery of
                                                                                                                                                                                                                                                                                                     the accounts and enact




                                                                                                                                                                             Collated by Pat Morris
                                                                                                                                                                             Head of Governance                                                                                                                                                            34
              Enclosure Oi                                                                                                                                                                                                                                                                                                                      Objective 9

                                                                                                                                                                                  Board Assurance Framework 2009-2010




Major Elements                                                                                                                                                                                                                                            Lead
                                                                                                                                                                                                                                                                                                                                                           Deadline

9.2       Identify key milestones and projects from the National Patient Safety Campaign for the Trust to implement                                                                                                                                       Medical Director                                                                                 6/30/2009


9.3       Implement local projects to improve patient safety within the Trust as part of the national campaign                                                                                                                                            Medical Director                                                                                 3/31/2010

                                                                                                       Current
                                                                                                       Totals
ID        Risks                           Initial Risk                                                                              Controls                     Assurances             Reported Assurances            Current Risk Gaps in Controls                                    Gaps in Assurance        Action Plan                Who               When
                                            Rating                                                                                                                                       Identified in Board Reports   Rating JUN
                                                                          Intial (Inherent)


                                                                                                                                                                                         and External Assessments
                                       Consequence




                                                                                                                                                                                                                       Consequence
                                                     Likelihood




                                                                                                                                                                                                                                     Likelihood
                                                                                                                  MARCH
                                                                                              JUNE
                                                                                                     SEPT
                                                                                                            DEC
                                                                  Total




                                                                                                                                                                                                                                                  Total
     454 Poor compliance with           4            3            12      12 12                      0      0      0 Patient Safety team                   Patient Safety Meeting                                       4             3           12 Clinical understanding                                 Develop and implement     Communications
         Patient Safety Targets due                                                                                                                                                                                                                                                                         a communication           Manager
         to lack of clinical                                                                                              Patient Safety team trained in   Clinical Governance                                                                            Faciliated Launch                                 strategy
         engagement                                                                                                       Leading Improvement
                                                                                                                          Global Trigger Tool in           Committee
                                                                                                                                                           Trust Board                                                                                    Mortality Group                                   Establish a mortality     Medical Director
                                                                                                                          Mortality Audit                  MAOGG                                                                                                                                            group
                                                                                                                                                                                                                                                                                                            Set-up a evening
                                                                                                                          Harm Events Audit                SAOGG                                                                                                                                            meeting with Clinicians
                                                                                                                          Workstreams identified
                                                                                                                          Dr Foster Real Time monitoring

                                                                                                                          Executive Walkrounds


     455 Inadequate resources to        3            3            9           9               9      0      0      0 Patient Safety group                  Patient Safety group                                         3             3           9       Administrative and audit                          Review resources          Associate Director     31/08/2009
         deliver the patient safety                                                                                                                        minutes                                                                                        support                                           required and develop      of Nursing/Head
         agenda                                                                                                                                                                                                                                                                                             business case             of Governance

                                                                                                                          MAOGG                            Divisional Governace                                                                           Lack of experience and                            Encourage clincians to    Medical Director          Ongoing
                                                                                                                                                           minutes                                                                                        trained clinicians to drive                       attend training
                                                                                                                                                                                                                                                          agenda
                                                                                                                                                        Clincial Governance                                                                                                                                 Develop audit skills of   Patient Safety            Ongoing
                                                                                                                          SAOGG                         Committee                                                                                                                                           clicians using the GTT    Manager
                                                                                                                          Members of the Patient Safety Trust Board
                                                                                                                          group trained in Leading
                                                                                                                          Improvement in Patient Safety
                                                                                                                          (LIPs)


     456 Poor knowledge of all Care     4            4            16      16 16                      0      0      0 Saving Lives Audits                   Infection Prevention Board                                   4             4           16 The Trust cannot                                       Patient Safety Team to Associate Director           Ongoing
         Bundles and their                                                                                                                                 Meetings                                                                                       demonstrate compliance                            identify workstream lead for Nursing
         implementation in the Trust                                                                                                                                                                                                                      with non- HCAI Care                               and priorities for
                                                                                                                          HCAI Care Bundles                Patient Safety Meetings                                                                        bundles                                           implementation

                                                                                                                                                           Clinical Governance                                                                                                                              Review care bundles     Head of                     Ongoing
                                                                                                                                                           Committee                                                                                                                                        and plan implementation Governance
                                                                                                                                                                                                                                                                                                            through workstreams




                                                                                                                                                                                         Collated by Pat Morris
                                                                                                                                                                                         Head of Governance                                                                                                                                                        35
              Enclosure Oi                                                                                                                                                                                                                                                                                                                            Objective 9

                                                                                                                                                                                  Board Assurance Framework 2009-2010




Major Element                                                                                                                                                                                                                                             Lead
                                                                                                                                                                                                                                                                                                                                                                 Deadline

9.4      Improve Hospital Standardised Mortality (HSMR) rate performance with the aim of being less than a 100 by the end of the year                                                                                                                     Medical Director                                                                                       3/31/2010

                                                                                                        Current
                                                                                                        Totals
ID       Risks                             Initial Risk                                                                              Controls                     Assurances            Reported Assurances            Current Risk Gaps in Controls                                  Gaps in Assurance                Action Plan                Who              When
                                             Rating                        Intial (Inherent)                                                                                             Identified in Board Reports   Rating JUN
                                                                                                                                                                                         and External Assessments
                                        Consequence




                                                                                                                                                                                                                       Consequence
                                                      Likelihood




                                                                                                                                                                                                                                     Likelihood
                                                                                                                   MARCH
                                                                                               JUNE
                                                                                                      SEPT
                                                                                                             DEC
                                                                   Total




                                                                                                                                                                                                                                                  Total
422      Incomplete documentation        5            3            15      15 10                      0      0      0 Clinical Coders                       Management Board                                            5             2           10 Incomplete discharge             Validating the            Mortality Group to be set- Medical Director        30/11/2009
         and coding of co-                                                                                                                                                                                                                                summaries                   documentation is complete up chaired by the
         morbidities                                                                                                       3 Accredidtaed Clincal Coders Patient Safety Group                                                                             Lack of availability of                               Medical Director
                                                                                                                                                                                                                                                          case-notes for coding
                                                                                                                           1 Accreditated Clinical Coder    Data Quality report                                                                                                       Reporting mechanisms for ToR of DQ Group to be        Associate Director
                                                                                                                           Auditor                                                                                                                                                    data quality within the  reviewed to establish        for Information &
                                                                                                                                                                                                                                                                                      revised committee        reporting mechanism          Performance
         Also on 4.1                                                                                                       Coding validated using NHS       Payment by Results (PbR)
                                                                                                                                                                                                                                                                                      structure
                                                                                                                           HRG Grouper                      Clinical Coding Audits
                                                                                                                           Audit Red Flags alerting in Dr   Trust Commissioned
                                                                                                                           Foster Real Time Monitoring      External Clinical Coding
                                                                                                                                                                                                                                                                                                                  To establish reporting    Medical Director       31/07/2009
                                                                                                                           Tool                             Audit
                                                                                                                                                                                                                                                                                                                  mechanism for the
                                                                                                                                                            Internal Clinical Coding                                                                                                                              Discharge Summary
                                                                                                                                                            Audits                                                                                                                                                Group



     457 Implementation of new           3            3            9           9               9      0      0      0                                                                                                   3             3           9       Project just starting -     Project just starting -      Project Board to assess Clinical Director       31/07/2009
         Pharmacy computer sytem                                                                                                                                                                                                                          process not yet in place    process not yet in place for risks, processes and    of Pharmacy
         may have a detrimanl                                                                                                                                                                                                                             for establising controls.   establising assurance.       controls to make
         impact on comletion of                                                                                                                                                                                                                                                                                    recommendations
         discarge summaries



     403 Inadequate internal             4            4            16      16 16                      0      0      0 Palliative Care Consultant                                                                        4             4           16 Poor implementation of           Issues not reported         Process for reporting     AGM for Cancer         31/07/2009
         resources to deliver End of                                                                                                                                                                                                                      the Liverpool Care          through the Trust           issues to be identified   Services
         Life Care                                                                                                         Lead Palliative Care Nurse                                                                                                     Pathway                     Committee Structures        and actioned

                                                                                                                           Cancer Unit                                                                                                                    Understanding of                                        Scoping of Trust's       Lead Palliative         31/08/2009
                                                                                                                                                                                                                                                          resources required                                      Palliative Care Services Care Nurse
                                                                                                                                                                                                                                                                                                                  and gaps identified
         Also on 3.5                                                                                                       Liverpool Care Pathway                                                                                                         Limited remit for                                       reported to Clinical
                                                                                                                                                                                                                                                          Community Supportive
                                                                                                                           Community Supportive Care                                                                                                      Care Pathway Facilitators
                                                                                                                           Pathway Facilitators


     404 Lack of clarity concerning      4            4            16      16 16                      0      0      0 MHS Warwickshire End of Life                                                                      4             4           16 Implication of the Strategy Issues not reported              Process for reporting     AGM for Cancer         31/07/2009
         community resources                                                                                               Care Strategy                                                                                                                  for the Trust               through the Trust           issues to be identified   Services
         relating to End of Life Care                                                                                                                                                                                                                                                 Committee Structures        and actioned


         Also on 3.5                                                                                                                                                                                                                                                                                              Strategy to be reviewed   Director of             7/31/2009
                                                                                                                                                                                                                                                                                                                  and implications for      Nursing &
                                                                                                                                                                                                                                                                                                                  Trust identified and      Operations
                                                                                                                                                                                                                                                                                                                  reported




                                                                                                                                                                                         Collated by Pat Morris
                                                                                                                                                                                         Head of Governance                                                                                                                                                             36
              Enclosure Oi                                                                                                                                                                                                                                                                                                                                Objective 9

                                                                                                                                                                                    Board Assurance Framework 2009-2010




          Take part in the National Review of Safeguarding Children arrangements implementing any recommendations within agreed
9.5                                                                                                                                                                                                                                                             Director of Operations & Nursing                                                                     3/31/2010
          timescales
                                                        Current
                                                         Totals
ID        Risks                   Initial Risk                            Controls           Assurances      Reported Assurances                                                                                             Current Risk Gaps in Controls                                  Gaps in Assurance              Action Plan                Who               When
                                    Rating                                                                    Identified in Board Reports                                                                                    Rating JUN

                                                                            Intial (Inherent)
                                                                                                                                                                                               and External Assessments
                                         Consequence




                                                                                                                                                                                                                             Consequence
                                                       Likelihood




                                                                                                                                                                                                                                           Likelihood
                                                                                                                    MARCH
                                                                                                JUNE
                                                                                                       SEPT
                                                                                                              DEC
                                                                    Total




                                                                                                                                                                                                                                                        Total
     458 Identified risks from initial    4            4            16      16 12                      0      0      0 Child protection training part of Attendance records of                                                4             3           12 Insufficient attendance by Reports of numbers of           Associate Director of     Associate Director        Ongoing
         benchmarking was                                                                                                   mandatory training for clinical   training                                                                                          medical staff               staff who have attended   Nursing to continue to    for Nursing
         insufficient staff trained in                                                                                      and non clinical staff                                                                                                                                          training                  deliver training plans
         child protection
                                                                                                                            Regular training identifed for    Quartely update and review                                                                        Not enough training                                   Adhoc training sessions Associate Director          Ongoing
                                                                                                                            medical staff                     of action plan at the Clinical                                                                    sessions available to                                 to be arranged          for Nursing
                                                                                                                                                              Quality Review held with                                                                          ensure all medical staff
                                                                                                                                                              PCT                                                                                               trained
                                                                                                                            Action plan in place following                                                                                                                                                            Reporting mechanism to Associate Director        31/07/2209
                                                                                                                            HCC review                                                                                                                                                                                be established         for Nursing

                                                                                                                            Quarterly training organised to
                                                                                                                            address issues


Major Element                                                                                                                                                                                                                                                   Lead
                                                                                                                                                                                                                                                                                                                                                                     Deadline

9.6       Implement new processes for managing the hospital at night                                                                                                                                                                                            Director of Operations & Nursing                                                                     9/30/2009

                                                                                                         Current
                                                                                                         Totals
ID        Risks                             Initial Risk                                                                              Controls                       Assurances                Reported Assurances           Current Risk Gaps in Controls                                  Gaps in Assurance              Action Plan                Who               When
                                              Rating                                                                                                                                           Identified in Board Reports   Rating JUN
                                                                            Intial (Inherent)




                                                                                                                                                                                               and External Assessments
                                         Consequence




                                                                                                                                                                                                                             Consequence
                                                       Likelihood




                                                                                                                                                                                                                                           Likelihood
                                                                                                                    MARCH
                                                                                                JUNE
                                                                                                       SEPT
                                                                                                              DEC
                                                                    Total




                                                                                                                                                                                                                                                        Total
     459 Gaps in recruitment to           2            4            8           8               6      0      0      0 Weekly monitoring of fill rate of Medical Education Cte;                                               2             3           6       External allocation                                   Establishment of LAS     AMD Clinical             7/31/2009
         doctors in training posts by                                                                                       posts locally                     Executive F&P Cte                                                                                 process                                               posts to cover vacancies Tutor
         the Deanery                                                                                                                                                                                                                                                                                                  in training posts




     460 New model not accepted           3            2            6           6               3      0      0      0 Critical Incident Reports              Executive F&P Committee                                         3            1            3       HAN Bleep system would                                Hospital at Night Bleep   Associate Director      9/30/2009
         through organisation                                                                                                                                                                                                                                   allow accurate mapping of                             agreed in principle.       for Information
                                                                                                                            Incident logs                     Hospital at Night feedback                                                                        workflow                                              Awaiting improved
                                                                                                                                                              sessions                                                                                                                                                wireless coverage

                                                                                                                            Handover reports




                                                                                                                                                                                                Collated by Pat Morris
                                                                                                                                                                                                Head of Governance                                                                                                                                                           37
            Enclosure Oi                                                                                                                                                                                                                                                                                         Objective 10

                                                                                                                                                                              Board Assurance Framework 2009-2010




          Principle Objective 10:                                           The Trust will continue to use Information Technology to improve processes within the Trust

          SfBH Domain                                                       Governance: Patient Focus

          Lead Director                                                     Finance Director

Major Element                                                                                                                                                                                                                                            Lead
                                                                                                                                                                                                                                                                                                                       Deadline

10.1      Improve PAS functionality and prepare a business case for further implementation of the national programme.                                                                                                                                    Director of Finance                                            3/31/2010

                                                                                                         Current
                                                                                                         Totals
ID        Risks                             Initial Risk                                                                             Controls                    Assurances             Reported Assurances           Current Risk Gaps in Controls                            Gaps in Assurance   Action Plan   Who     When
                                              Rating                                                                                                                                    Identified in Board Reports   Rating JUN
                                                                            Intial (Inherent)




                                                                                                                                                                                        and External Assessments
                                         Consequence




                                                                                                                                                                                                                      Consequence
                                                       Likelihood




                                                                                                                                                                                                                                    Likelihood
                                                                                                                    MARCH
                                                                                                JUNE
                                                                                                       SEPT
                                                                                                              DEC
                                                                    Total




                                                                                                                                                                                                                                                 Total
     461 Delay in implementing            4             3           12      12 12                      0      0      0 PAS Implementation Group to Timely delivery of upgrade                                          4             3           12
         LE2.2                                                                                                              be re-instated and chaired by and asscoiated training for
                                                                                                                            Director of Ops. Issues Fed up relevant staff
                                                                                                                            through Trust IMT Board and
                                                                                                                            through DF to Board as
                                                                                                                            appropriate




     462 Difficulty in having a fixed     3             4           12      12 12                      0      0      0 Case for "joined" up working      Signed off case by Trust                                      3             4           12
         idea on the availability of                                                                                        across Coventry and          Board
         Lorenzo and hence the                                                                                              Warwickshire Health Economy
         ability to deliver a business                                                                                      to be made and used as basis
         case with appropriate                                                                                              for Trust case.
         timescakes and costs




                                                                                                                                                                                        Collated by Pat Morris
                                                                                                                                                                                        Head of Governance                                                                                                                  38
            Enclosure Oi                                                                                                                                                                                                                                                                                                           Objective 10

                                                                                                                                                                        Board Assurance Framework 2009-2010




Major Element                                                                                                                                                                                                                                   Lead
                                                                                                                                                                                                                                                                                                                                                  Deadline
         Improve Trust website with input from members and patients to ensure that it is used as a useful source of information that is
10.2                                                                                                                                                                                                                                            CEO/Trust Secretary                                                                                 11/30/2009
         current and useful for patients, public and local GPs
                                                         Current
                                                          Totals
ID       Risks                   Initial Risk                          Controls                Assurances        Reported Assurances                                                                         Current Risk Gaps in Controls                                     Gaps in Assurance       Action Plan                 Who              When
                                   Rating                                                                         Identified in Board Reports                                                                Rating JUN
                                                                          Intial (Inherent)                                                                                       and External Assessments
                                       Consequence




                                                                                                                                                                                                             Consequence
                                                     Likelihood




                                                                                                                                                                                                                           Likelihood
                                                                                                                  MARCH
                                                                                              JUNE
                                                                                                     SEPT
                                                                                                            DEC
                                                                  Total




                                                                                                                                                                                                                                        Total
     447 Insufficent IT staffing        2            4            8           8               8      0      0      0 Prioritise process for accessing Management Board minutes                                2             4           8       Training of staff outside of                       Improve technical         Associate Director     30/09/2009
         resource to design, deliver                                                                                      Shared Services           - quarterly                                                                                 Shared Services to                                 design of the Trust       for IT
         changes and maintain the                                                                                                                                                                                                               maintain content                                   website to enable non-
         site content                                                                                                                               Trust IT Committtee minutes                                                                                                                    technical administrator
                                                                                                                                                                                                                                                                                                   to update content
                                                                                                                                                                                                                                                Easy to use structure of
                                                                                                                                                                                                                                                Website for non-technical
                                                                                                                                                                                                                                                administrators
         Same as 7.3

                                                                                                                                                                                                                                                                                                   Administrators to be      Associate Director     30/11/2009
                                                                                                                                                                                                                                                                                                   trained in updating       for IT
                                                                                                                                                                                                                                                                                                   website
     464 The content of the website     2            3            6           6               6      0      0      0 Patient's Forum                Patient Experience Group                                  2             3           6       Member's Survey                                    To develop and            Membership             11/30/2009
         is not useful because it is                                                                                                                minutes                                                                                                                                        implement a Member's      Officer
         unrepresentative of the                                                                                                                                                                                                                                                                   Survey
         public view                                                                                                      Membership Officer        Governors                                                                                   Governors Induction                                To develop and            Membership             12/31/2009
                                                                                                                                                                                                                                                Programme                                          implement a Governor's    Officer
                                                                                                                          Members                   Governors meetings                                                                                                                             Induction Programme

                                                                                                                          Website Hit Rate          Trust Board minutes                                                                         Schedule of Govenors                               To set-up the schedule    Membership             30/09/2009
                                                                                                                                                                                                                                                Meetings                                           for the Governors         Officer
                                                                                                                                                    Patient Survey Results                                                                                                                         Meetings

                                                                                                                                                    Trust IT Committee minutes                                                                  User group                                         To develop and         Communications            30/11/2009
                                                                                                                                                                                                                                                                                                   implement a Trust User Manager
                                                                                                                                                                                                                                                                                                   group



     465 The GP's do not use the        2            3            6           6               6      0      0      0 Clinical Reference Group       Management Board minutes                                  2            3            6       User group                                         To develop and         Communications            30/11/2009
         website because the                                                                                              Meeting                                                                                                                                                                  implement a Trust User Manager
         content is not valuable                                                                                                                                                                                                                                                                   group
                                                                                                                          GP's Survey               Governors

                                                                                                                          Website Hit Rate          Shadow Council of
                                                                                                                                                    Governors
                                                                                                                                                    GP Referral Analysis (Dr
                                                                                                                                                    Foster)
                                                                                                                                                    Trust IT Committee minutes




                                                                                                                                                                                  Collated by Pat Morris
                                                                                                                                                                                  Head of Governance                                                                                                                                                    39
             Enclosure Oi                                                                                                                                                                                                                                                                                                                       Objective 10

                                                                                                                                                                        Board Assurance Framework 2009-2010




                                                                                                        Current
                                                                                                        Totals
ID         Risks                           Initial Risk                                                                             Controls                 Assurances           Reported Assurances           Current Risk Gaps in Controls                                             Gaps in Assurance        Action Plan                  Who              When
                                             Rating                                                                                                                               Identified in Board Reports   Rating JUN




                                                                           Intial (Inherent)
                                                                                                                                                                                  and External Assessments
                                        Consequence




                                                                                                                                                                                                                Consequence
                                                      Likelihood




                                                                                                                                                                                                                                  Likelihood
                                                                                                                   MARCH
                                                                                               JUNE
                                                                                                      SEPT
                                                                                                             DEC
                                                                   Total




                                                                                                                                                                                                                                                   Total
           Insufficient                  2             4           8           8               8      0      0      0 Communications Manager                                                                                  2                4   8       User Group                                         To develop and         Trust Secretary/            30/11/2009
           Communications resource                                                                                                                                                                                                                                                                            implement a Trust User Communications
           to manage website content                                                                                                                                                                                                                                                                          group                  Manager
     466
                                                                                                                                                                                                                                                           Training of staff outside IT                       Improve technical           Associate Director     30/10/2009
                                                                                                                                                                                                                                                           Shared Services to                                 design of the Trust         for IT
                                                                                                                                                                                                                                                           maintain content                                   website to enable non-
                                                                                                                                                                                                                                                                                                              technical administrator
                                                                                                                                                                                                                                                                                                              to update content
                                                                                                                                                                                                                                                                                                              Administrators to be        Associate Director     30/10/2009
                                                                                                                                                                                                                                                                                                              trained in updating         for IT
                                                                                                                                                                                                                                                                                                              website


Major Element                                                                                                                                                                                                                                              Lead
                                                                                                                                                                                                                                                                                                                                                               Deadline
           Fully implement the 18 week Status Manager and the software to support the monitoring of performance against the new
10.3                                                                                                                                                                                                                                                       Director of Operations & Nursing                                                                       4/30/2009
           cancer targets
                                                       Current
                                                        Totals
ID         Risks                  Initial Risk                           Controls              Assurances       Reported Assurances                                                                             Current Risk Gaps in Controls                                             Gaps in Assurance        Action Plan                  Who              When
                                    Rating                                                                       Identified in Board Reports                                                                    Rating JUN
                                                                           Intial (Inherent)




                                                                                                                                                                                  and External Assessments
                                        Consequence




                                                                                                                                                                                                                Consequence
                                                      Likelihood




                                                                                                                                                                                                                                  Likelihood
                                                                                                                   MARCH
                                                                                               JUNE
                                                                                                      SEPT
                                                                                                             DEC
                                                                   Total




                                                                                                                                                                                                                                                   Total
     467 Insufficiently accurate data    4            3            12      12 12                      0      0      0 Primary Target List (PTL)        Weekly Workload Planning                                  4                 3               12 PTL part of Status                                      Review the Status           18 week Manager         7/31/2009
         available to manage 18                                                                                                                        meeting                                                                                             Manager to complex for                             Manager information
         week pathways                                                                                                                                                                                                                                     Users                                              analysis further testing
                                                                                                                           Status Manager (SM)         Executive F&P
                                                                                                                           Access Policy               Monthly performance                                                                                                                                    Further testing to see if   18 week Manager         7/31/2009
                                                                                                                                                       reports                                                                                                                                                fit for purpose
                                                                                                                           18wks Manager


     468 Non 18wk targets are not        4            2            8           8               8      0      0      0 Primary Target List (PTL)        Weekly Workload Planning                                               4                2   8       The Status Manager does                            Review of status            18 week Manager         8/31/2009
         explicitly displayed in SM                                                                                                                    meeting                                                                                             not presently provide                              manager to configure
         and could lead to inpatient                                                                                                                                                                                                                       data relating to non-18                            information to aid
         / diagnostic breaches                                                                                                                                                                                                                             week performance targets                           pathway management

                                                                                                                           Cancer pathway monitoring   Executive F&P
                                                                                                                           18wks Manager               Monthly performance
                                                                                                                                                       reports
                                                                                                                           Cancer Services Manager




                                                                                                                                                                                  Collated by Pat Morris
                                                                                                                                                                                  Head of Governance                                                                                                                                                                 40
            Enclosure Oi                                                                                                                                                                                                                                                                                                                    Objective 10

                                                                                                                                                                               Board Assurance Framework 2009-2010




                                                                                                         Current
                                                                                                         Totals
ID        Risks                             Initial Risk                                                                              Controls                     Assurances          Reported Assurances           Current Risk Gaps in Controls                                        Gaps in Assurance       Action Plan              Who            When
                                              Rating                                                                                                                                   Identified in Board Reports   Rating JUN




                                                                            Intial (Inherent)
                                                                                                                                                                                       and External Assessments
                                         Consequence




                                                                                                                                                                                                                     Consequence
                                                       Likelihood




                                                                                                                                                                                                                                       Likelihood
                                                                                                                    MARCH
                                                                                                JUNE
                                                                                                       SEPT
                                                                                                              DEC
                                                                    Total




                                                                                                                                                                                                                                                       Total
     485 Incomplete data being            4            3            12      12 12                      0      0      0 Data quality validation monthly Weekly Workload Planning                                                    4                3 12 Inhouse database is                                  To work with the Data   Cancer Services      6/30/2009
         uploaded which may affect                                                                                                                           meeting                                                                                           unable to analyse the                          Quality Analyst to      Manager
         the Trust achievement of                                                                                           Manual Cancer Pathway            Executive F&P                                                                                     complexity of the cancer                       identify gaps in the
         the Cancer Targets                                                                                                 monitoring                                                                                                                         targets
                                                                                                                            Cancer Services Manager          Monthly performance                                                                                                                              To work with the IT     Cancer Services      6/30/2009
                                                                                                                                                             reports                                                                                                                                          Developer to ensure     Manager
                                                                                                                            Data Quality Analyst                                                                                                                                                              database is fit for
                                                                                                                                                                                                                                                                                                              purpose



Major Element                                                                                                                                                                                                                                                  Lead
                                                                                                                                                                                                                                                                                                                                                        Deadline

10.4      Review the business case for PACs and develop a plan to realise maximum benefits from the implementation                                                                                                                                             Director of Operations & Nursing                                                            9/30/2009

                                                                                                         Current
                                                                                                         Totals
ID        Risks                             Initial Risk                                                                              Controls                     Assurances          Reported Assurances           Current Risk Gaps in Controls                                        Gaps in Assurance       Action Plan              Who            When
                                              Rating                                                                                                                                   Identified in Board Reports   Rating JUN
                                                                            Intial (Inherent)




                                                                                                                                                                                       and External Assessments
                                         Consequence




                                                                                                                                                                                                                     Consequence
                                                       Likelihood




                                                                                                                                                                                                                                       Likelihood
                                                                                                                    MARCH
                                                                                                JUNE
                                                                                                       SEPT
                                                                                                              DEC
                                                                    Total




                                                                                                                                                                                                                                                       Total
     486 Improvement in turn              3            4            12      12 12                      0      0      0 Job Plans                             Executive F&P            Executive F&P minutes           3                 4              12 Insufficient capacity                               Outsourcing Plain Film AGM Radiology        31/07/2009
         around times of reporting                                                                                                                                                    (26/05)                                                                                                                 and MRI Reporting from
         of images doesn’t achieve                                                                                          Additional Consultant Sessions                                                                                                     Consultant Vacancy                             July for a trial period of
                                                                                                                                                                                                                                                                                                              To evaluate the impact AGM Radiology        30/11/2009
         the target set (48hrs)                                                                                                                                                                                                                                                                               of the trial and make
                                                                                                                                                                                                                                                                                                              recommendations
                                                                                                                            Monitor weekly levels of                                                                                                                                                          AGM & Medical Director AGM Radiology        31/03/2009
                                                                                                                            reporting                                                                                                                                                                         to review Job Plans

                                                                                                                            Monitor weekly productivity of
                                                                                                                            Consultant


     487 Images not readily               5            2            10      10 10                      0      0      0 System managed by external            Faults reported to CSC                                   5                 2              10
         available for review by                                                                                            contractors (CSC/UE Medical
         clinicans if there is network                                                                                      Systems) who have
         or sytem failure                                                                                                   contingency plans

                                                                                                                            Internal Contingency Plan
                                                                                                                            PACS Manager


Major Element                                                                                                                                                                                                                                                  Lead
                                                                                                                                                                                                                                                                                                                                                        Deadline

10.5      Enable access to the Internet from mobile devices - No risks expected as should be in place by 30th June 2009                                                                                                                                        Director of Finance                                                                        12/31/2010




                                                                                                                                                                                       Collated by Pat Morris
                                                                                                                                                                                       Head of Governance                                                                                                                                                     41
           Enclosure Oi                                                                                                                                                                                                                                                                                                                    Objective 11

                                                                                                                                                                             Board Assurance Framework 2009-2010




         Principle Objective 11:                                           The Trust will continue to develop governance arrangements across the Trust

         SfBH Domain                                                       Governance

         Lead Director                                                     CEO

Major Element                                                                                                                                                                                                                                          Lead
                                                                                                                                                                                                                                                                                                                                                  Deadline

11.1     Establish the Foundation Trust governance arrangements                                                                                                                                                                                        Trust Secretary                                                                            6/30/2009

                                                                                                        Current
                                                                                                        Totals
ID       Risks                             Initial Risk                                                                               Controls                   Assurances          Reported Assurances            Current Risk Gaps in Controls                                   Gaps in Assurance             Action Plan             Who        When
                                             Rating                                                                                                                                   Identified in Board Reports   Rating JUN
                                                                           Intial (Inherent)




                                                                                                                                                                                      and External Assessments
                                        Consequence




                                                                                                                                                                                                                    Consequence
                                                      Likelihood




                                                                                                                                                                                                                                  Likelihood
                                                                                                                   MARCH
                                                                                               JUNE
                                                                                                      SEPT
                                                                                                             DEC
                                                                   Total




                                                                                                                                                                                                                                               Total
     469 The Trust is not authorised     4            3            12      12 12                      0      0      0 FT Project Team                      Trust Board                                               4             3           12 Revised Project Plan              Date for Care Quality    Agree trajectory with   CEO &          17/06/2009
         during the year 2009-2010                                                                                         Governors                       StHa Assessment                                                                             Unclear timing of re-        Commission (CQC)         Monitor                 Chairman
                                                                                                                                                                                                                                                       assessment                   assessment
                                                                                                                           StHa FT Lead                    Care Quality Commission                                                                                                                           Revise Project Plan     Trust          31/07/2009
                                                                                                                                                           Assessment                                                                                                                                                                Secretary
                                                                                                                                                                                                                                                                                                             Reconvene Project       Trust          30/06/2009
                                                                                                                                                           HDD Assessment                                                                                                                                    Team                    Secretary      16/06/2009
                                                                                                                                                                                                                                                                                                             Agree timescale for CQC CEO            30/06/2009
                                                                                                                                                                                                                                                                                                             review



     470 The delay to authorisation      3            3            9           9               9      0      0      0 Membership Office                    Trust Board                                               3             3           9       Governors Induction          Governors meeting        To develop and         Membership       12/31/2009
         leads to a loss of                                                                                                Membership Officer                                                                                                          programme                    reporting to Board       implement a Governor's Officer
         governors engagement                                                                                                                                                                                                                                                                                Induction Programme
                                                                                                                                                                                                                                                       Governors meetings
                                                                                                                                                                                                                                                                                    FT Status Report to Board Set-up reporting       Trust          30/06/2009
                                                                                                                                                                                                                                                                                                              mechanism to Board     Secretary



     471 Governors have a lack of        3            3            9           9               9      0      0      0 Membership Office                    Trust Board                                               3             3           9
         clarity regarding the                                                                                             Membership Officer
         shadow role
                                                                                                                           Chairman




     472 The Non-executives are          4            2            8           8               8      0      0      0 Direct Reports from F&P              Trust Board                                               4             2           8       Sufficient time at Board                              To review Board Agenda Chairman        31/10/2009
         are not sufficiently assured                                                                                      Executive through appropriate   Executive Finance &                                                                         meetings to fully consider                            to ensure enough time is CEO
         on finance and                                                                                                    Executive at Board Meeting      Performance                                                                                 finance and performance                               allocated for debate of
                                                                                                                                                                                                                                                                                                                                      Trust
         performance matters                                                                                                                                                                                                                           matters                                               F&P matters
                                                                                                                                                                                                                                                                                                                                      Secretary
                                                                                                                           Board Access to additional
                                                                                                                           performance data
                                                                                                                           Schedule of Business
                                                                                                                           Board Workshops


Major Element                                                                                                                                                                                                                                          Lead
                                                                                                                                                                                                                                                                                                                                                  Deadline




                                                                                                                                                                                     Collated by Pat Morris
                                                                                                                                                                                     Head of Governance                                                                                                                                                       42
           Enclosure Oi                                                                                                                                                                                                                                                                                                        Objective 11

                                                                                                                                                                            Board Assurance Framework 2009-2010




11.2     Facilitating communication between our membership and the elected governors                                                                                                                                                                      Trust Secretary                                                               6/30/2009

                                                                                                      Current
                                                                                                      Totals
ID       Risks                           Initial Risk                                                                              Controls                      Assurances             Reported Assurances            Current Risk Gaps in Controls                            Gaps in Assurance       Action Plan           Who          When
                                           Rating                                                                                                                                        Identified in Board Reports   Rating JUN


                                                                         Intial (Inherent)
                                                                                                                                                                                         and External Assessments
                                      Consequence




                                                                                                                                                                                                                       Consequence
                                                    Likelihood




                                                                                                                                                                                                                                     Likelihood
                                                                                                                 MARCH
                                                                                             JUNE
                                                                                                    SEPT
                                                                                                           DEC
                                                                 Total




                                                                                                                                                                                                                                                  Total
     470 The delay to authorisation    3            3            9           9               9      0      0      0 Membership Office                      Trust Board                                                  3             3           9       Governors Induction                       To develop and         Membership      12/31/2009
         leads to a loss of                                                                                                                                                                                                                               programme                                 implement a Governor's Officer
         governors engagement                                                                                            Membership Officer                                                                                                                                                         Induction Programme

                                                                                                                                                                                                                                                          Governors meetings                        Set-up reporting      Trust           30/06/2009
                                                                                                                                                                                                                                                          arrangements                              mechanism to Board    Secretary
         Same as 11.1

Major Element                                                                                                                                                                                                                                             Lead
                                                                                                                                                                                                                                                                                                                                        Deadline
         Ensure new Finance and Performance Executive committee arrangements are embedded, then disband current Finance and
11.3                                                                                                                                                                                                                                                      Director of Finance                                                           6/30/2009
         Performance Committee
                                                    Current
                                                    Totals
ID       Risks                Initial Risk                           Controls          Assurances        Reported Assurances                                                                                           Current Risk Gaps in Controls                            Gaps in Assurance       Action Plan           Who          When
                                Rating                                                                    Identified in Board Reports                                                                                  Rating JUN
                                                                         Intial (Inherent)




                                                                                                                                                                                         and External Assessments
                                      Consequence




                                                                                                                                                                                                                       Consequence
                                                    Likelihood




                                                                                                                                                                                                                                     Likelihood
                                                                                                                 MARCH
                                                                                             JUNE
                                                                                                    SEPT
                                                                                                           DEC
                                                                 Total




                                                                                                                                                                                                                                                  Total
     473 Loss of appropriate           4            2            8           8               8      0      0      0 The Board will still receive           Delivery against financial                                   4             2           8
         understanding of finance                                                                                        monthly Finance and               and performance targets
         and performance at Trust                                                                                        Performance reports with detail   and exceptions and actions
         Board                                                                                                           available monthly and             being taken to ensure
                                                                                                                         considered every quarter.         delivery.


     474 Lack of appropriate           4            3            12      12 12                      0      0      0 Terms of Reference -                   Delivery against financial                                   4             3           12
         engagement at Divisional                                                                                        meetings arranged to ensure       and performance targets
         Level.                                                                                                          clinical input                    and exceptions and actions
                                                                                                                                                           being taken to ensure
                                                                                                                                                           delivery.




                                                                                                                                                                                        Collated by Pat Morris
                                                                                                                                                                                        Head of Governance                                                                                                                                          43
           Enclosure Oi                                                                                                                                                                                                                                                                                                                Objective 11

                                                                                                                                                                              Board Assurance Framework 2009-2010




Major Element                                                                                                                                                                                                                                             Lead
                                                                                                                                                                                                                                                                                                                                                Deadline

11.4     Ensure arrangements in place for effective Self Certification                                                                                                                                                                                    Trust Secretary                                                                       6/30/2009

                                                                                                        Current
                                                                                                        Totals
ID       Risks                             Initial Risk                                                                             Controls                     Assurances              Reported Assurances           Current Risk Gaps in Controls                            Gaps in Assurance            Action Plan              Who          When
                                             Rating                                                                                                                                      Identified in Board Reports   Rating JUN
                                                                           Intial (Inherent)                                                                                             and External Assessments
                                        Consequence




                                                                                                                                                                                                                       Consequence
                                                      Likelihood




                                                                                                                                                                                                                                     Likelihood
                                                                                                                   MARCH
                                                                                               JUNE
                                                                                                      SEPT
                                                                                                             DEC
                                                                   Total




                                                                                                                                                                                                                                                  Total
     475 Non-executive feeling           5            2            10      10 10                      0      0      0 Assurance Framework                  Trust Board                  Trust Board (19/02/2009)        5             2           10 Comprehensive                                       Establish Compliance    Head of          31/08/2009
         insufficiently assured to be                                                                                                                                                                                                                     Assurance                                      Unit                    Governance
         able to self certify                                                                                              Board Reports                   Clinical Governnace
                                                                                                                                                           Committee
                                                                                                                           Licenced with the CQC for the                                                                                                                                                 Co-ordinate the           Manager of     31/03/2009
                                                                                                                           Health Act                                                                                                                                                                    collection of evidence to Compliance
                                                                                                                                                           Unannounced visits from                                                                                                                       enable the Trust to be    Unit
                                                                                                                                                           the CQC                                                                                                                                       licenced with the CQC

                                                                                                                                                           Concordant Letter from the
                                                                                                                                                           Concordant

                                                                                                                                                           SfBh Declaration

Major Element                                                                                                                                                                                                                                             Lead
                                                                                                                                                                                                                                                                                                                                                Deadline

11.5     Develop membership recruitment policy and deliver against trajectory                                                                                                                                                                             Trust Secretary                                                                       Ongoing

                                                                                                        Current
                                                                                                        Totals
ID       Risks                             Initial Risk                                                                             Controls                     Assurances              Reported Assurances           Current Risk Gaps in Controls                            Gaps in Assurance            Action Plan              Who          When
                                             Rating                                                                                                                                      Identified in Board Reports   Rating JUN
                                                                           Intial (Inherent)




                                                                                                                                                                                         and External Assessments
                                        Consequence




                                                                                                                                                                                                                       Consequence
                                                      Likelihood




                                                                                                                                                                                                                                     Likelihood
                                                                                                                   MARCH
                                                                                               JUNE
                                                                                                      SEPT
                                                                                                             DEC
                                                                   Total




                                                                                                                                                                                                                                                  Total
     476 Failure to gain FT Status       2            3            6           6               6      0      0      0 Membership Officer                   Trust Board                                                  2             3           6       Governors Induction   Governors meetings       To develop and         Membership         12/31/2009
         leads to loss of Public                                                                                                                                                                                                                          programme             reporting to Board       implement a Governor's Officer
         Interest                                                                                                          Membership Office               FT Project Team                                                                                                                               Induction Programme
                                                                                                                           Governors                                                                                                                      Governors meetings    FT Status Report to Board Set-up reporting       Trust            30/06/2009
                                                                                                                                                                                                                                                          arrangements                                    mechanism to Board     Secretary
                                                                                                                           Membership Strategy




                                                                                                                                                                                        Collated by Pat Morris
                                                                                                                                                                                        Head of Governance                                                                                                                                                  44
           Enclosure Oi                                                                                                                                                                                                                                                                                                                   Objective 11

                                                                                                                                                                           Board Assurance Framework 2009-2010




Major Element                                                                                                                                                                                                                                            Lead
                                                                                                                                                                                                                                                                                                                                                    Deadline

11.6     Strengthen the governance arrangements of all Shared Services                                                                                                                                                                                   CEO                                                                                        4/30/2009

                                                                                                        Current
                                                                                                        Totals
ID       Risks                             Initial Risk                                                                                 Controls                Assurances             Reported Assurances            Current Risk Gaps in Controls                                  Gaps in Assurance           Action Plan             Who           When
                                             Rating                                                                                                                                     Identified in Board Reports   Rating JUN
                                                                           Intial (Inherent)                                                                                            and External Assessments
                                        Consequence




                                                                                                                                                                                                                      Consequence
                                                      Likelihood




                                                                                                                                                                                                                                    Likelihood
                                                                                                                   MARCH
                                                                                               JUNE
                                                                                                      SEPT
                                                                                                             DEC
                                                                   Total




                                                                                                                                                                                                                                                 Total
     477 Review of Pathology             3            2            6           6               6      0      0      0 Health Strategy Board               Trust Board                                                  3             2           6                                   Ernst & Young Report   CEO to report back on    CEO &            31/07/2009
         Governance arrangements                                                                                                                                                                                                                                                                            implications of Report   Chairman
         by UHCW may reduce our                                                                                            Shared Services Board          Risk Management Board
         influence                                                                                                         General Manager for Support    Finance & Performance
                                                                                                                           Services                       Executive for Support
                                                                                                                                                          Services
                                                                                                                           Medical Director

                                                                                                                           Internal Governance
                                                                                                                           arrangements



     488 IT Developments do not          4            3            12      12 12                      0      0      0 Associate Director of IT            Management Board                                             4             3           12 IT Plan for the Trust                                   Develop IT Plan and      Associate        31/07/2009
         support the Trust's strategy                                                                                                                                                                                                                                                                       gain approval by TB      Director for
         due to an uncoordinated                                                                                           IT Shared Services                                                                                                                                                                                        Performance
         approach                                                                                                          Programme Board                                                                                                                                                                                           and

                                                                                                                           Trust IT Committee

Major Element                                                                                                                                                                                                                                            Lead
                                                                                                                                                                                                                                                                                                                                                    Deadline
         Complete encryption of data on portable devices and promote secure practice principles regarding all Trust and departmental
11.7                                                                                                                                                                                                                                                     Medical Director                                                                               9/30/2009
         systems
                                                      Current
                                                       Totals
ID       Risks                 Initial Risk                            Controls               Assurances         Reported Assurances                                                                                  Current Risk Gaps in Controls                                  Gaps in Assurance           Action Plan             Who           When
                                 Rating                                                                          Identified in Board Reports                                                                          Rating JUN
                                                                           Intial (Inherent)




                                                                                                                                                                                        and External Assessments
                                        Consequence




                                                                                                                                                                                                                      Consequence
                                                      Likelihood




                                                                                                                                                                                                                                    Likelihood
                                                                                                                   MARCH
                                                                                               JUNE
                                                                                                      SEPT
                                                                                                             DEC
                                                                   Total




                                                                                                                                                                                                                                                 Total
     478 Information held on non-        4            2            8           8               8      0      0      0 IM&T Security Policy                IG Steering Group Agenda                                     4             2           8       Data Encryption Policy to                          Ratify Data Encryption   IG Manager &     30/09/2009
         encrypted portable devices                                                                                                                       Item                                                                                           be ratified by the Trust                           Policy                   ITSS
         may be lost if the device is                                                                                      Laptop Usage Policy            Regular Communications to                                                                                                                         Roll Out Encrypted
         lost/stolen                                                                                                                                      All Staff on Data Security                                                                                                                        Portable Media to
                                                                                                                                                                                                                                                                                                            Authorised Recipients
                                                                                                                           Draft Data Encryption Policy   Information Flow Mappings                                                                                                                         Implement Port Access
                                                                                                                                                                                                                                                                                                            Control (lock down USB
                                                                                                                                                                                                                                                                                                            ports)
                                                                                                                           IG Toolkit                     Information Governance                                                                                                                            Communication Strategy
                                                                                                                                                          Training Sessions                                                                                                                                 to accompany above




                                                                                                                                                                                       Collated by Pat Morris
                                                                                                                                                                                       Head of Governance                                                                                                                                                       45
           Enclosure Oi                                                                                                                                                                                                                                                                                                            Objective 11

                                                                                                                                                                         Board Assurance Framework 2009-2010




                                                                                                    Current
                                                                                                    Totals
ID       Risks                         Initial Risk                                                                                 Controls                 Assurances             Reported Assurances            Current Risk Gaps in Controls                                  Gaps in Assurance        Action Plan             Who          When
                                         Rating                                                                                                                                      Identified in Board Reports   Rating JUN




                                                                       Intial (Inherent)
                                                                                                                                                                                     and External Assessments
                                    Consequence




                                                                                                                                                                                                                   Consequence
                                                  Likelihood




                                                                                                                                                                                                                                 Likelihood
                                                                                                               MARCH
                                                                                           JUNE
                                                                                                  SEPT
                                                                                                         DEC
                                                               Total




                                                                                                                                                                                                                                              Total
     479 Person identifiable or      4            2            8           8               8      0      0      0 IM&T Security Policy                IG Steering Group Agenda                                      4             2           8       Data Encryption Policy to                       Ratify Data Encryption   IG Manager &     30/09/2009
         commercially sensitive                                                                                                                       Item                                                                                            be ratified by the Trust                        Policy                   ITSS
         data may leave the Trust                                                                                      Email Usage Policy             Regular Communications to                                                                                                                       Roll Out Encrypted
         via email or hard copy                                                                                                                       All Staff on Data Security                                                                                                                      Portable Media to
         printout                                                                                                                                                                                                                                                                                     Authorised Recipients
                                                                                                                       IG Toolkit                     Information Flow Mappings                                                                                                                       Implement Port Access
                                                                                                                                                                                                                                                                                                      Control (lock down USB
                                                                                                                                                                                                                                                                                                      ports)
                                                                                                                       Draft Data Encryption Policy   Information Governance                                                                                                                          Communication Strategy
                                                                                                                                                      Training Sessions                                                                                                                               to accompany above




Major Element                                                                                                                                                                                                                                         Lead
                                                                                                                                                                                                                                                                                                                                              Deadline

11.8     Ensure the Trust achieves a minimum of Level 2 as measured by the Information Governance Toolkit                                                                                                                                             Medical Director                                                                          12/31/2009

                                                                                                    Current
                                                                                                    Totals
ID       Risks                         Initial Risk                                                                                 Controls                 Assurances             Reported Assurances            Current Risk Gaps in Controls                                  Gaps in Assurance        Action Plan             Who          When
                                         Rating                                                                                                                                      Identified in Board Reports   Rating JUN
                                                                       Intial (Inherent)




                                                                                                                                                                                     and External Assessments
                                    Consequence




                                                                                                                                                                                                                   Consequence
                                                  Likelihood




                                                                                                                                                                                                                                 Likelihood
                                                                                                               MARCH
                                                                                           JUNE
                                                                                                  SEPT
                                                                                                         DEC
                                                               Total




                                                                                                                                                                                                                                              Total
     480 Not all requirements        4            2            8           8               16     0      0      0 IG Toolkit                          Full-time Information                                         4             2           8       Updates to the IG Toolkit                       Information Governance Requirement        31/12/2009
         achieve level 2 in the                                                                                                                       Governance Manager                                                                              requirements not in place                       Manager to work closely Owners & IG
         Information Governance                                                                                                                       starting at the end of July                                                                     until the end of June                           with requirement owners Manager
         (IG) Toolkit                                                                                                                                                                                                                                                                                 to make sure they fully
                                                                                                                                                                                                                                                                                                      understand and
                                                                                                                                                                                                                                                                                                      evidence their
                                                                                                                                                                                                                                                                                                      requirements up to a
                                                                                                                                                                                                                                                                                                      level 2


                                                                                                                       IG Steering Group              Trust Board                                                                                                                                     Evidence checked on a
                                                                                                                                                                                                                                                                                                      regular basis by IG
                                                                                                                       Policy Review Group            Requirement Owners                                                                              Substantive IG Manager                          Manager
                                                                                                                                                      Central Repository for                                                                                                                          Full-time Information
                                                                                                                                                      evidence                                                                                                                                        Governance Manager
                                                                                                                                                                                                                                                                                                      starting at the end of
                                                                                                                                                                                                                                                                                                      July




                                                                                                                                                                                    Collated by Pat Morris
                                                                                                                                                                                    Head of Governance                                                                                                                                                46
            Enclosure Oi                                                                                                                                                                                                                                                                                                                   Objective 12

                                                                                                                                                                               Board Assurance Framework 2009-2010




          Principle Objective 12:                                           The Trust will maintain high scores for the Quality of Services

          SfBH Domain                                                       All Domains

          Lead Director                                                     Director of Operations & Nursing

Major Element                                                                                                                                                                                                                                                Lead                                                                                    Deadline
12.1      Achieve a Quality of Service rating of at least 'Good' by the Care Quality Commission                                                                                                                                                              Director of Operations & Nursing                                                        3/31/2010

                                                                                                         Current
                                                                                                         Totals
ID        Risks                             Initial Risk                                                                               Controls                   Assurances                Reported Assurances           Current Risk Gaps in Controls                                 Gaps in Assurance        Action Plan              Who           When
                                              Rating                                                                                                                                        Identified in Board Reports   Rating JUN
                                                                            Intial (Inherent)




                                                                                                                                                                                            and External Assessments
                                         Consequence




                                                                                                                                                                                                                          Consequence
                                                       Likelihood




                                                                                                                                                                                                                                        Likelihood
                                                                                                                    MARCH
                                                                                                JUNE
                                                                                                       SEPT
                                                                                                              DEC
                                                                    Total




                                                                                                                                                                                                                                                     Total
     272 Insufficient standards or        4            2            8           8               8      0      0      0 Each standard has an                Monthly Trust Board                                             4             2           8
         national targets achieved                                                                                          assigned accountable senior    Perfromanc Report of
         to gain Good rating.                                                                                               manager                        compliance
                                                                                                                            Programme of assurance for     Included in the Internal audit
                                                                                                                            each SfBH standard to be       programme
                                                                                                                            reviewed by Executive F&P at
                                                                                                                            least once during the year


     489 Insufficient national targets    4            3            12      12                  8      0      0      0 Manager assigned for each           Quarterly Performance                                           4             2           8
         achieved overall                                                                                                   target                         Matrix to Management
                                                                                                                                                           Board and by exception to
                                                                                                                                                           Trust Board

     490 Delays in radiology              3            3            9           9               9      0      0      0 Radiology Manager                   Weekly Workload Planning                                        3            3            9       Lack of understanding of                       Implement a Service       Health           31/03/2010
         investigations lengthen 18                                                                                                                        meeting                                                                                           capcity and productivity                       Improvement               Foundation
         week and Cancer pathways                                                                                                                                                                                                                                                                           Programme                 Project Lead
                                                                                                                            18 week Manager                Executive F&P                                                                                     Inadequate radiographers
                                                                                                                                                                                                                                                             to enable extend day
                                                                                                                                                                                                                                                             working
                                                                                                                            Cancer Services manager                                                                                                                                                         Implement outsourcing     AGM for          31/07/2009
                                                                                                                                                                                                                                                                                                            of Radiology Reporting    Radiology
                                                                                                                            Weekly monitoring of Wait                                                                                                                                                       Recruitment Drive for     AGM for             Ongoing
                                                                                                                            Times                                                                                                                                                                           Radiographers             Radiology
                                                                                                                                                                                                                                                                                                            Use of Locum              AGM for             Ongoing
                                                                                                                                                                                                                                                                                                            Radiographers             Radiology

     491 Recruitment of Theatre           3            4            12      12 12                      0      0      0 Weekly theatre session              Monthly manpower                                                3            4            12 Annual leave guidelines                             Continous recruitment     AGM Critical        Ongoing
         staff is insufficient to                                                                                           planning                       assessment                                                                                                                                       process                   Care
         increase capacity to
         planned level

                                                                                                                            Locum Staff                    Executive F&P                                                                                     Review of job plans by                         Develop Annual Leave      GM - Surgery     30/06/2009
                                                                                                                                                                                                                                                             AMDs supported by                              Guidelines and aoorival
                                                                                                                                                                                                                                                             AGMs                                           ay management
                                                                                                                                                                                                                                                                                                            boardand implem

                                                                                                                                                                                                                                                                                                            Impleemnt Annual Leave Medical             31/07/2009
                                                                                                                                                                                                                                                                                                            Guideleins             Director
                                                                                                                                                                                                                                                                                                            Undertake Job Plan     AMD Surgery         30/09/2009
                                                                                                                                                                                                                                                                                                            Reviews supported by
                                                                                                                                                                                                                                                                                                            AGMs




                                                                                                                                                                                            Collated by Pat Morris
                                                                                                                                                                                            Head of Governance                                                                                                                                                   47
            Enclosure Oi                                                                                                                                                                                                                                                                                                            Objective 12

                                                                                                                                                                          Board Assurance Framework 2009-2010




                                                                                                      Current
                                                                                                      Totals
ID       Risks                           Initial Risk                                                                             Controls                        Assurances      Reported Assurances           Current Risk Gaps in Controls                                     Gaps in Assurance        Action Plan             Who       When
                                           Rating                                                                                                                                 Identified in Board Reports   Rating JUN




                                                                         Intial (Inherent)
                                                                                                                                                                                  and External Assessments
                                      Consequence




                                                                                                                                                                                                                Consequence
                                                    Likelihood




                                                                                                                                                                                                                              Likelihood
                                                                                                                 MARCH
                                                                                             JUNE
                                                                                                    SEPT
                                                                                                           DEC
                                                                 Total




                                                                                                                                                                                                                                           Total
     482 Trust fails the 4 hour A&E    3            4            12      12                  9      0      0      0 Hospital Operational Manager Monthly Board Performance                                       3             3           9       An effective emergency                             Implement new team       AMDs          01/08/2009
         Target                                                                                                                                          report                                                                                    medical pathway                                    structure pathway        Medicine

                                                                                                                         Escalation Procedure in A&E     Monthly Executive F&P                                                                     Consistency of See &
                                                                                                                                                                                                                                                   Treat
                                                                                                                         Daily performance information                                                                                                                                                Full implemention of     AMDs          01/10/2009
                                                                                                                                                                                                                                                                                                      acute physcian team      Medicine
                                                                                                                         Daily bed management                                                                                                      Consistency in Bed                                 Fully implement new      GM for        31/07/2009
                                                                                                                         meetings and communication                                                                                                Management                                         nursing structure        Medicine
                                                                                                                         process                                                                                                                                                                      supporting see & treat
                                                                                                                                                                                                                                                   Adequate Bed capacity                              Bed management          GM for         30/06/2009
                                                                                                                                                                                                                                                                                                      procedure and           Medicine
                                                                                                                                                                                                                                                                                                      guidelines reviewed and
                                                                                                                                                                                                                                                                                                      updated to Management
                                                                                                                                                                                                                                                                                                      Board for approval


                                                                                                                                                                                                                                                   Observation Unit not fit for                       Build new Block          Director of   30/11/2009
                                                                                                                                                                                                                                                   purpose                                                                     Development
                                                                                                                                                                                                                                                                                                      Build new Observation    Director of   31/10/2009
                                                                                                                                                                                                                                                                                                      Unit                     Development




                                                                                                                                                                                 Collated by Pat Morris
                                                                                                                                                                                 Head of Governance                                                                                                                                                48
            Enclosure Oi                                                                                                                                                                                                                                                                                                             Objective 12

                                                                                                                                                                       Board Assurance Framework 2009-2010




Major Element                                                                                                                                                                                                                                       Lead
                                                                                                                                                                                                                                                                                                                                               Deadline

12.2     Achieve Level 2 for Maternity Services                                                                                                                                                                                                     Director of Operations & Nursing                                                              12/4/2009

                                                                                                        Current
                                                                                                        Totals
ID       Risks                             Initial Risk                                                                              Controls              Assurances             Reported Assurances            Current Risk Gaps in Controls                            Gaps in Assurance                Action Plan             Who           When
                                             Rating                                                                                                                               Identified in Board Reports    Rating JUN
                                                                           Intial (Inherent)                                                                                      and External Assessments
                                        Consequence




                                                                                                                                                                                                                 Consequence
                                                      Likelihood




                                                                                                                                                                                                                               Likelihood
                                                                                                                   MARCH
                                                                                               JUNE
                                                                                                      SEPT
                                                                                                             DEC
                                                                   Total




                                                                                                                                                                                                                                            Total
     483 Failure to achieve level 2      4            3            12      12 12                      0      0      0 Project group established and Monthly progress report to   Clinical Governance Minutes &    4             3           12 Low level of clinical      Awaiting confirmation from Audit midwife to liaise   Audit Midwife     30/06/2009
         resulting in loss of premium                                                                                      meets every 2 weeks       Clinical Governance         Report (09/04, 14/05,11/06)                                        engagement            assessor regarding levels with assessor re
                                                                                                                                                     Committee                                                                                                            of evidence required       evidence
                                                                                                                           Project plan in place                                                                                                    Failure to deliver
                                                                                                                                                                                                                                                    documents to agreed
                                                                                                                           Project lead appointed                                                                                                                                                     To monitor progress of   Audit Midwife     31/10/2009
                                                                                                                                                                                                                                                    timescales
                                                                                                                                                                                                                                                                                                      documents and ensure
                                                                                                                           Lead named individuals                                                                                                                                                     timescales are met



     484 Failure to achieve level 1      5            3            15      15 15                      0      0      0 Project group established and Monthly progress report to   Clinical Governance Minutes &    5             3           15 Low level of clinical                                  To communicate with      Medical           30/06/2009
         due to the amount of                                                                                              meets every 2 weeks       Clinical Governance         Report (09/04, 14/05,11/06)                                        engagement                                        Clinicians what is       Director
         documents required                                                                                                                          Committee                                                                                                                                        required and to what
                                                                                                                           Project plan in place                                                                                                    Failure to deliver
         resulting in loss of                                                                                                                                                                                                                                                                         timescales
                                                                                                                           Project lead appointed                                                                                                   documents to agreed
         reputation
                                                                                                                                                                                                                                                    timescales
                                                                                                                           Lead named individuals                                                                                                                                                     To monitor progress of   Audit Midwife     31/10/2009
                                                                                                                                                                                                                                                                                                      documents and ensure
                                                                                                                                                                                                                                                                                                      timescales are met




                                                                                                                                                                                 Collated by Pat Morris
                                                                                                                                                                                 Head of Governance                                                                                                                                                    49

								
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