Glossary by decree

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									Glossary for Assurance Framework
Reference                     Description
A&E                           Accident and Emergency
AHC                           Annual Health Check (by the Healthcare Commission)
ALE Report                    Auditors Local Evaluation
ARP                           Ambulance Radio Programme
CNST                          Clinical Negligence Scheme for Trusts
DAT                           Dorset Ambulance Trust
DATIX                         Risk Management Database
DoH                           Department of Health
E&D                           Equality and Diversity
ERIC Return                   Estates Return Information Collection
H&S                           Health and Safety
HFMA                          Healthcare Financial Management Association
ICT                           Information Computer Technology
JD                            Job Description
JRCALC                        Joint Royal Colleges Ambulance Liaison Committee
KO41                          Submission and Data Concerning Complaints
KSF                           Knowledge & Skills Framework
NEDs                          Non-Executive Director
NHSLA                         National Health Service Litigation Authority
OSCs                          Overview Scrutiny Committee
PCT                           Primary Care Trust
PIP                           Performance Improvement Plan
PPI Forum                     Patient &Public Involvement Forum
PPI Strategy                  Patient &Public Involvement Strategy
PR                            Public Relations
PRF                           Performance Review Framework
Psiam                         Decision Support Software
RPST                          Risk Pooling Scheme
S4BH                          Standards for Better Health
SDC                           Service Development Committee
SFI                           Standing Financial Instruction
SHA                           Strategic Health Authorities
SO                            Standing Orders
STEIS                         Strategic Executive Information System
SWAST                         South Western Ambulance Service Trust
TPfIT Group                   Trust Programme for Information Technology
VFM                           Value for Money




                       Glossary - Assurance Framework SWAST                4/19/2010
         South Western Ambulance Service NHS Trust




                                    Assurance Framework for 2008/09




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Background
All NHS Trusts, including Foundation Trusts, are required to provide an Assurance Framework as a mechanism for the Board to ensure the effective and focused management of principal risks to the
achievement of key objectives. This Framework has been developed for 2008/09 incorporating recommendations made following an annual review by Internal Audit.

Assurance Framework
The assurance frameworks for the two former trusts identified key objectives under the headings of the Standards for Better Health domains. This Assurance Framework is presented differently in
that it contains, at a high level, the key objectives of the Trust which have been grouped under separate headings for clarity, including those relating to the Standards for Better Health. The
Framework identifies the principal risks associated with achievement of objectives and details controls and assurances which are already in place. It also identifies any gaps in those controls and
assurances and responsibility for managing those gaps, or for providing positive assurance, is allocated to individuals, committees and action plans. The Assurance Framework is intended to be a
dynamic document which is not fixed in time, although timescales are included and progress against them will be incorporated and reported upon.
Reporting Arrangements
It is recognised that a more planned and considered approach should be taken over the provision of information to Trust Boards. To that end, this Framework is intended to provide Board members
with the assurance they require that any risk to achievement of Trust objectives is managed, whilst reducing the amount of paperwork discussed at Boards to that which is most relevant. This will be
achieved by ensuring that a committee, chaired by a Non Executive Director, is allocated to each objective and that progress against the related action plans is monitored and reported upon by the
Chair of the Committee. An Annual Board Cycle will set the programme for information to be presented to the Trust Board at each meeting throughout the year and will help to support this process by
ensuring that Board members receive the most appropriate information to enable them to fulfil their role.

Review of Framework
The Assurance Framework will be managed by the Head of Governance and will be reported to the Trust Board at each meeting. At the end of each financial year (ie at the March Board) the
Assurance Framework will be 'closed' for the year and a new document started for the following year. Action for the previous year will be summarised in the new document where relevant.
Any gaps in controls and/or assurance will remain identified in the relevant column for the year and a report will be provided at the end of the year regarding any which have not been
addressed/controlled.

Management of Framework
Action points from the Assurance Framework will be a standing agenda item for each committee with responsibilities against actions, and progress reported via their minutes (copied to the Board) and
through reports to the Board by the Chair of the Committee. The Head of Governance will ensure that the Committee Chairs receive up to date copies of their actions.
The Directors Group will monitor progress against the entire document on a monthly basis and feed back to the Head of Governance that the review has taken place and any actions arising from that
review.
All Board and committee papers will identify links to the Assurance Framework with clear references. These will then be updated on the Framework itself each month. These references will also be
added to the Board or Committee Paper Record which is a comprehensive record of all business discussed at or by the Board and its committees. The Board will review the updated Framework at
each meeting.
Version Control
The Framework will be document controlled by means of version numbers at the bottom of each page. It will include the Version number and the relevant month as well as the committee to which it is
presented. No items will be removed without the approval of the Board.
This document was approved for 2008/09 at the April Board Away Day
This version has been updated by quarter (attached to the framework) following:
Governance Committees in May, July, September, November, January
Board meetings in April, May, July, September, November, January
Board Seminars in June, November and December
Audit Committees in April, June, August, October, December and February
Better Value Better Care Committee in May (now FT Steering Committee)
FT Steering Committee in January and February
Directors Group meetings from May to 3rd February




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            Risk                                                                                                                                                             Gaps in




                                                                                                                                                                                                                                                                                                                                                    Group
                                                                                                           Risk




                                                                                                                                                                                                                                                            Role
                                                                                                                                                   Positive Assurances on                  Gaps in                              Other Action/ Action
Ref        Register                 Type                                   Objective                                     Key controls/ systems                               Controls/                      Measurement
                                                                                                          Rating                                           Controls                       Assurance                                    Plans
             Ref                                                                                                                                                             Systems
                                     Corporate Objective
                                                           1. To deliver national requirements,         Sig (4) x      Performance Management    Performance Management     none         none identified *Performance reports   Performance




                                                                                                                                                                                                                                                            Chief Executive
                                                           national priorities for local delivery and   Unlikely (2)   Framework                 Reports                    identified                   to Board               Improvement Plan
              EXEC/ CO 315




                                                           local priorities for action as set out in    =              Directorate Objectives




                                                                                                                                                                                                                                                                                                                                                    Directors
AF/01/08




                                                           the Operational Plans 2008/09 -              Significant    Performance Improvement
                                                           2010/11                                                     Plan Group




                                                           2. To achieve an excellent rating for        Sig (4) x      Performance Management    Performance Management     none         none identified *Performance reports   Quality of Services




                                                                                                                                                                                                                                                            Director of Urgent Care and Clinical Services Head of PR and Strategic Communications
                                                           Quality of Services and an excellent         Unlikely (2)   Framework                 Reports                    identified                   to Board               (inc S4BH) Action
                                                           rating for Use of Resources as               =              Directorate Objectives    Compliance Assurance                                    *Compliance            Plan            Use of
                                                           determined by the Healthcare                 Significant    Head of Governance        Reports                                                 Assurance Reports      Resources (ALE)
                                                           Commission                                                  Compliance Manager                                                                                       Action Plan
              GOV/ CO 316 and 317



                                     Corporate Objective




                                                                                                                       Compliance Audits                                                                                        ALE 'Panel'




                                                                                                                                                                                                                                                                                                                                                    Governance
AF/02/08




                                                           3. To increase the utilisation of clinical tbc              Performance Management    Performance Management     none         none identified *Performance reports   No specific action
                                                           resources by: *reducing the incidence                       Framework                 Reports                    identified                   to Board               plan
                                                           of dual deployment of Rapid Response                        Directorate Objectives
                                                           Vehicles Paramedics and Emergency
                                                           Ambulances xx% to yy%; *reducing the
                                     Corporate Objective




                                                           on scene time of Rapid Response
                                                           Vehicles from xx minutes to yy minutes
              OPS/ CO 320




                                                                                                                                                                                                                                                                                                                                                    Directors
AF/03/08




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            Risk                                                                                                                                                            Gaps in




                                                                                                                                                                                                                                                                                                                                            Group
                                                                                                         Risk




                                                                                                                                                                                                                                                             Role
                                                                                                                                                  Positive Assurances on                    Gaps in                              Other Action/ Action
Ref        Register                 Type                                 Objective                                     Key controls/ systems                                Controls/                        Measurement
                                                                                                        Rating                                            Controls                         Assurance                                    Plans
             Ref                                                                                                                                                            Systems


                                                                                                    tbc




                                                                                                                                                                                                                                                             Director of Finance and Performance Director of HR and Workforce Development
                                                           4. To develop clinical skills in minor                    Performance Management     Performance Management     none           none identified *Performance reports   Workforce Plan
                                                           ailments and minor injuries with a                        Framework                  Reports                    identified                     to Board
                                                           measurable: *increase in the number of                    Directorate Objectives
                                                           patients attending minor injury units by                  Training and Education
                                                           ambulance from x to y; *decrease in                       Strategy
                                     Corporate Objective




                                                           the number of admissions to A&E from
                                                           x to y
              HR/ CO 323




                                                                                                                                                                                                                                                                                                                                            Directors
AF/04/08




                                                           5. To implement service line reporting,    Sig (4) x    Performance Management       Performance Management     Service line   none identified *Performance reports   No specific action
                                                           and agree a framework for                  Unlikely (2) Framework                    Reports                    reporting                      to Board               plan
                                                           commissioning ambulance services           =            Directorate Objectives                                  framework




                                                                                                                                                                                                                                                                                                                                            FT Steering Committee
                                                           with PCTs including the development        Significant
                                     Corporate Objective
              FIN/ CO 318 and 319




                                                           of a local price tariff
AF/05/08




                                                                                                                                                                                                                                                                                                                                            Equality and Diversity
                                                           6. To embed Equality and Diversity in      Low (2) x      Performance Management     Performance Management     none           none identified *Performance reports   No specific action
                                     Corporate Objective
              HR/ CO 321 and 322




                                                           the Trust so that the patient experience   Unlikely (2)   Framework                  Reports                    identified                     to Board               plan




                                                                                                                                                                                                                                                             Chief Executive
                                                           improves from x to y and that employee     = Moderate     Directorate Objectives
AF/06/08




                                                           satisfaction improves from x to y          Moderate       Equality and Diversity
                                                                                                      (3) x          Strategy and Action Plan
                                                                                                      Unlikely (2)
                                                                                                      = Moderate




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            Risk                                                                                                                                                           Gaps in




                                                                                                                                                                                                                                                                                                                                         Group
                                                                                                        Risk




                                                                                                                                                                                                                                                           Role
                                                                                                                                                 Positive Assurances on                   Gaps in                              Other Action/ Action
Ref        Register                 Type                                   Objective                                  Key controls/ systems                                Controls/                       Measurement
                                                                                                       Rating                                            Controls                        Assurance                                    Plans
             Ref                                                                                                                                                           Systems


                                                           7. To identify measurable                 Low (2) x    Performance Management       Performance Management     No          regular reports *Performance reports     Environmental Action




                                                                                                                                                                                                                                                           Head of PR and Strategic Communications Director of Finance and Performance
                                                           improvements in environmental             Unlikely (2) Framework                    Reports                    Environment required to     to Board                 Plan
                                                           performance and reductions in             = Moderate Directorate Objectives                                    al action   directors
                                                           pollution                                              Environmental Policy                                    plan
                                     Corporate Objective
              EV/ CO 324




                                                                                                                                                                                                                                                                                                                                         Directors
AF/07/08




                                                           8. To develop a strong and vibrant        Significant    Performance Management     Performance Management     none          none identified *Performance reports   No specific action
                                                           reputation, well respected by patients,   (4) x          Framework                  Reports                    identified                    to Board               plan
                                                           the public and all stakeholders with      Unlikely (2)   Directorate Objectives
                                                           staff proud to be an integral part of a   =              Head of PR and Strategic
                                                           successful and dynamic trust.             Significant    Communications
                                     Corporate Objective
              PIR/ CO 324 and 325




                                                                                                     Moderate
                                                                                                     (3) x




                                                                                                                                                                                                                                                                                                                                         Directors
AF/08/08




                                                                                                     Unlikely (2)
                                                                                                     = Moderate




                                                           Board to fulfil its statutory duties      Moderate       Standing Orders and        Review of SO/SFIs          Process for   none identified *Annual Board Cycle   Process to Identify
                                                                                                     (3) x          Financial Instructions     Assurance Reports from     identifying                   and Board Agendas     Breach of SO/SFI
                                     Board Objectives




                                                                                                                                                                                                                                                           Chief Executive
                                                                                                     Unlikely (2)   Appointment of New NED     Board Sub Committees       breach of                     and Reports
                                                                                                     = Moderate     Head of Governance         Board Self Assessment      SO/SFI                        *Board Sub Committee
              GOV 273
AF/09/08




                                                                                                                                                                                                                                                                                                                                         Audit
                                                                                                                    Governance Committee       Board Training                                           Assurance Reports and
                                                                                                                    Audit Committee                                                                     Minutes
                                                                                                                    Assurance Framework                                                                 *Assurance Framework
                                                                                                                    Annual Board Cycle                                                                  Updates
                                                                                                                                                                                                        *SO/SFI Annual
                                                                                                                                                                                                        Review




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            Risk                                                                                                                                              Gaps in




                                                                                                                                                                                                                                                                 Group
                                                                                     Risk




                                                                                                                                                                                                                                               Role
                                                                                                                                Positive Assurances on                      Gaps in                                Other Action/ Action
Ref        Register     Type                             Objective                              Key controls/ systems                                         Controls/                       Measurement
                                                                                    Rating                                              Controls                           Assurance                                      Plans
             Ref                                                                                                                                              Systems
                         Board Objective
                                           Review Board progress/ development     Moderate     Annual Board Cycle             Minutes from Board            none          none identified *Training undertaken     Training to be




                                                                                                                                                                                                                                               Chief Executive
                                                                                  (3) x        including Self Assessment      Seminars                      identified                    by Board members         identified
              GOV 273
AF/10/08




                                                                                  Unlikely (2)                                Evidence of Board Training




                                                                                                                                                                                                                                                                 Audit
                                                                                  = Moderate                                  and Development



                                           Review Governance reporting pathway none           ALE report                      ALE report                    none          none identified *Board Sub Committee No specific action
                         Board Objective




                                                                                                                                                                                                                                               Chief Executive
                                           throughout Trust.                                  External Audit Reviews          External Audit reports        identified                    Assurance Reports      plan




                                                                                                                                                                                                                                                                 Governance
                                                                                              Internal Audit Reviews          Internal Audit reports                                      *Statement of Internal
AF/11/08




                                                                                              Annual Health Check             Information Governance                                      Control
                                                                                              Audit Committee                 Toolkit
                                                                                              Statement of Internal Control   Annual Health Check
                                                                                                                              Statement of Internal Control




                                                                                                                                                                                                                                                                 FT Steering Committee
                                           Establish project Team for Foundation none         Strategic Direction             Reports from Better Value,    No project    none identified *Project team reports    FT Project Plan
                                           Trust application                                  Better Value, Better Care       Better Care Committee         plan or
                         Board Objective




                                                                                                                                                                                                                                               Chief Executive
                                                                                              Committee                                                     steering
AF/12/08




                                                                                                                                                            group
                                                                                                                                                            established




                                           Continually review new legislation and tbc         Legal box on Board paper  Board papers and minutes            No process    none identified *Board papers on new     Set 'new legislation'
                         Board Objective




                                           ensure it is applied as appropriate and            front covers. Guidance on of meetings                         for                           legislation              as a standing item on




                                                                                                                                                                                                                                               Directors

                                                                                                                                                                                                                                                                 Directors
                                           relevant                                           Seeking Legal Advice                                          identifying                                            Directors Group
AF/13/08




                                                                                                                                                            new                                                    and/or Board
                                                                                                                                                            legislation                                            meetings to ensure
                                                                                                                                                                                                                   that changes are
                                                                                                                                                                                                                   highlighted and
                                                                                                                                                                                                                   discussed




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            Risk                                                                                                                                                                                   Gaps in




                                                                                                                                                                                                                                                                                                                              Group
                                                                                                                             Risk




                                                                                                                                                                                                                                                                                    Role
                                                                                                                                                                      Positive Assurances on                     Gaps in                                 Other Action/ Action
Ref        Register     Type                                                                            Objective                          Key controls/ systems                                   Controls/                       Measurement
                                                                                                                            Rating                                            Controls                          Assurance                                       Plans
             Ref                                                                                                                                                                                   Systems
                        Annual Health Check - Quality of Services - Compliance with Core

                                                                                           Sustain compliance with Core   High (5) x     Safeguarding Manager        Safeguarding Reports        none          none identified *Safeguarding reports     Quality of Services
                                                                                           Standard Safety Domain         Unlikely (2)   Risk Manager                Infection Control Reports   identified                    to each Governance        (inc S4BH) Action
                                                                                                                          =              Medical Devices Co-         Health & Safety Group                                     and Board                 Plan
                                                                                                                          Significant    ordinator                   Reports                                                   *Compliance               Health & Safety
                                                                                                                                         Clinical Development        Compliance Assurance                                      Assurance Reports to      Action Plan




                                                                                                                                                                                                                                                                                    Head of PR and Strategic Communications
                                                                                                                                         Managers                    Reports                                                   each Governance and       Infection Control
                                                                                                                                         Health, Safety & Security   Internal Audit Reports                                    Board       *Infection    Action Plan
                                                                                                                                         Manager                     Level 2 NHSLA assessment                                  Control Action Plan       Engagement in NPSA
                                                                                                                                         Compliance Assurance        outcome                                                   Updates                   Patient Safety
                                                                                                                                         Audits                      Incident Reporting Policy                                 *Health, Safety &         Campaign in 2008
                                                                                                                                         Internal Audit Reviews      and Process                                               Security Governance




                                                                                                                                                                                                                                                                                                                              Governance
                                                  Standards
              GOV 235
AF/14/08




                                                                                                                                         Level 3 NHSLA               SUI Master Action Plan                                    and Board Reports
                                                                                                                                         Risk Management Support     SABS Procedure                                            *Internal Audit Reports
                                                                                                                                         Officer/ SABS Liaison       CRB Policy       Diagnostic                               to Audit Committee
                                                                                                                                         Officer                     & Therapeutic Equipment                                   *NHSLA Assessment
                                                                                                                                         Medical Devices Co-         Policy     Procurement                                    Report
                                                                                                                                         ordinator                   Manual       Medicines                                    *Governance
                                                                                                                                         Pharmaceutical Advisor      Management Strategy                                       Committee Assurance
                                                                                                                                                                     Waste Management                                          Reports to Board
                                                                                                                                                                     Contracts and Processes                                   *Medical Devices
                                                                                                                                                                                                                               Reports to H&S Group
                                                                                                                                                                                                                               *Incident Reports
                                                                                                                                                                                                                               *Premises Reviews
                                                                                                                                                                                                                               Reports




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            Risk                                                                                                                                                                                        Gaps in




                                                                                                                                                                                                                                                                                                                                             Group
                                                                                                                             Risk




                                                                                                                                                                                                                                                                                             Role
                                                                                                                                                                         Positive Assurances on                          Gaps in                                  Other Action/ Action
Ref        Register     Type                                                                            Objective                          Key controls/ systems                                        Controls/                           Measurement
                                                                                                                            Rating                                               Controls                               Assurance                                        Plans
             Ref                                                                                                                                                                                        Systems


                                                                                           Sustain compliance with Core   High (5) x     Director of Urgent Care &      Clinical Effectiveness Group none              none identified *Clinical Performance      Quality of Services
                                                                                           Standard Clinical and Cost     Unlikely (2)   Clinical Services              minutes              Clinical identified                       Board Reports              (inc S4BH) Action




                                                                                                                                                                                                                                                                                             Director of Urgent Care and Clinical Services
                        Annual Health Check - Quality of Services -




                                                                                           Effectiveness Domain           =              Clinical Audit & Research      Performance Board Reports                                      *Clinical Effectiveness    Plan
                                                                                                                          Significant    Manager                        Clinical Audit Plan 2008/09                                    Reports to Governance      Clinical Audit Plan
                            Compliance with Core Standards




                                                                                                                                         Clinical Development           Internal Audit Reports                                         *Medicines                 2008/09
                                                                                                                                         Managers (East and West)       Clinical News                                                  Management Reports
                                                                                                                                         Clinical Support Officers      Compliance Assurance                                           to Governance
                                                                                                                                         Clinical Supervisors (Hubs)    Reports                                                        *Compliance




                                                                                                                                                                                                                                                                                                                                             Governance
                                                                                                                                         Pharmaceutical Advisor         Implementation of Clinical                                     Assurance Reports to
              GOV 235
AF/15/08




                                                                                                                                         Clinical Effectiveness Group   Guidelines Policy                                              each Governance and
                                                                                                                                         Compliance Assurance           KSF/PDR Process                                                Board *Internal Audit
                                                                                                                                         Audits                         Training & Education Policy                                    Reports
                                                                                                                                         Internal Audit Reviews         Strategic Partnership Matrix                                   *Governance
                                                                                                                                         Medical Advisory Groups                                                                       Committee Assurance
                                                                                                                                                                                                                                       Reports to Board
                        Annual Health Check - Quality of Services - Compliance with Core




                                                                                           Sustain compliance with Core   High (5) x     External Audit reviews         ALE report                     Slippage on     Monitoring       *ALE report               Use of Resources
                                                                                           Standard Governance Domain     Unlikely (2)   Internal Audit reviews         SIC                            IG score of 7   required by      *Statement of Internal    (ALE) Work
                                                                                                                          =              ALE Panel                      Code of Conduct                percentage      Governance in    Control                   Programme 2008/09
                                                                                                                          Significant    Information Governance Self    Assurance Framework            points          2008/09 to       *Internal Audit Reports   Establish ALE Panel
                                                                                                                                         Assessment       Healthcare    SO/ SFIs                       No              ensure actions   *IG Action Plan reports   Quality of Services




                                                                                                                                                                                                                                                                                             Head of PR and Strategic Communications
                                                                                                                                         Commission Reviews             Board Paper Record             Whistleblowi    are caught up    to Governance             (inc S4BH) Action
                                                                                                                                         Annual Health Check            Performance Management         ng Policy                        *IG Toolkit Outturn       Plan       Information
                                                                                                                                         LCFS                           Framework                                                       Report to Governance      Governance Action
                                                                                                                                         Lead Commissioner's            Internal Audit reports    IG                                    and Board                 Plan
                                                                                                                                         Reviews                        Toolkit Outturn       Annual                                    *Annual Health Check      Clinical Governance
                                                                                                                                         ORH Reviews                    Health Check                                                    Rating 2007/08            Development Plan




                                                                                                                                                                                                                                                                                                                                             Governance
                                                  Standards
              GOV 235
AF/16/08




                                                                                                                                         Quality Monitoring by          Reports from                                                    *Quality Monitoring       Equality & Diversity
                                                                                                                                         Commissioners                  Commissioners                                                   Meeting Reports for       Action Plan
                                                                                                                                         Clinical Governance            Compliance Assurance                                            OOH                *CG    Whistleblowing Policy
                                                                                                                                         Development Plan               Reports                                                         Development Plan
                                                                                                                                         Governance Team                CG Development Plan                                             Updates to
                                                                                                                                                                        Whistleblowing Leaflet                                          Governance
                                                                                                                                                                        Records Management Policy                                       *Compliance
                                                                                                                                                                        Strategies: (E&D; Integrated                                    Assurance Reports to
                                                                                                                                                                        Governance; Information                                         each Governance and
                                                                                                                                                                        Governance ; Risk                                               Board
                                                                                                                                                                        Management; Health &                                            *Governance
                                                                                                                                                                        Safety)                                                         Committee Assurance
                                                                                                                                                                        Research Governance                                             Reports to Board
                                                                                                                                                                        Policy                                                          *KSF Reports




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            Risk                                                                                                                                                                                 Gaps in




                                                                                                                                                                                                                                                                                                                            Group
                                                                                                                         Risk




                                                                                                                                                                                                                                                                                  Role
                                                                                                                                                                   Positive Assurances on                      Gaps in                                 Other Action/ Action
Ref        Register     Type                                                                  Objective                                Key controls/ systems                                     Controls/                       Measurement
                                                                                                                        Rating                                             Controls                           Assurance                                       Plans
             Ref                                                                                                                                                                                 Systems
                        Annual Health Check - Quality of Services - Compliance

                                                                                 Sustain compliance with Core         High (5) x     Head of PR and Strategic    OSCs' commentaries on          none         none identified *OSC commentaries         Equality & Diversity
                                                                                 Standard Patient Focus Domain        Unlikely (2)   Communications              Annual Health Check            identified                   included in declaration   Action Plan
                                                                                                                      =              HR Business Manager         Declaration                                                 *E&D Committee            Quality of Services




                                                                                                                                                                                                                                                                                  Head of PR and Strategic Communications
                                                                                                                      Significant    Complaints Process          Complaints KO41 return                                      Assurance Reports to      (inc S4BH) Action
                                                                                                                                     Compliance Assurance        Complaints Policy                                           Board                     Plan
                                                                                                                                     Audits.                     Patient satisfaction surveys                                *Patient Experience
                                                                                                                                     Internal Audit Reviews      Patient Experience Reports                                  Reports to Board
                                        with Core Standards




                                                                                                                                     Disclosure (DPA and FoIA)   Internal Audit reports to                                   Quarterly and
                                                                                                                                     Processes                   Audit Committee                                             Governance




                                                                                                                                                                                                                                                                                                                            Governance
                                                                                                                                                                 Compliance Assurance                                        *Internal Audit Reports
              GOV 235
AF/17/08




                                                                                                                                                                 Reports                                                     *Compliance
                                                                                                                                                                 Code of Conduct                                             Assurance Reports to
                                                                                                                                                                 PPI and Community                                           each Governance and
                                                                                                                                                                 Engagement Strategy,                                        Board
                                                                                                                                                                 Equality and Diversity                                      *Governance
                                                                                                                                                                 Strategy                                                    Committee Assurance
                                                                                                                                                                 Strategic Direction                                         Reports to Board
                                                                                                                                                                 Fair Processing Strategy




                                                                                 Sustain compliance with Core         High (5) x     Head of PR and Strategic    Patient survey results         none         none identified *Patient Experience     Quality of Services
                        Annual Health Check - Quality of Services -




                                                                                                                                                                                                                                                                                  Head of PR and Strategic Communications
                                                                                 Standard Accessible and Responsive   Unlikely (2)   Communications              Information for patients       identified                   Reports to Governance (inc S4BH) Action
                                                                                 Care Domain                          =              HR Business Manager         Compliance Assurance                                        and Board Quarterly     Plan
                            Compliance with Core Standards




                                                                                                                      Significant    PPI and Community           Reports                                                     *Compliance
                                                                                                                                     Engagement Strategy         Internal Audit Reports                                      Assurance Reports to
                                                                                                                                     E&D Strategy                                                                            each Governance and
                                                                                                                                     Patient Surveys                                                                         Board         *Internal




                                                                                                                                                                                                                                                                                                                            Governance
                                                                                                                                     Compliance Assurance                                                                    Audit Reports
              GOV 235
AF/18/08




                                                                                                                                     Audits                                                                                  *Clinical Performance
                                                                                                                                     Internal Audit Reviews                                                                  Reports to each Board
                                                                                                                                                                                                                             *E&D Committee
                                                                                                                                                                                                                             Assurance Reports to
                                                                                                                                                                                                                             Board
                                                                                                                                                                                                                             *Governance
                                                                                                                                                                                                                             Committee Assurance
                                                                                                                                                                                                                             Reports to Board




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            Risk                                                                                                                                                                                          Gaps in




                                                                                                                                                                                                                                                                                                                                  Group
                                                                                                                                     Risk




                                                                                                                                                                                                                                                                                            Role
                                                                                                                                                                                Positive Assurances on                   Gaps in                                Other Action/ Action
Ref        Register                       Type                                                           Objective                                 Key controls/ systems                                  Controls/                         Measurement
                                                                                                                                    Rating                                              Controls                        Assurance                                      Plans
             Ref                                                                                                                                                                                          Systems


                                                                                          Sustain compliance with Core            High (5) x     Health, Safety & Security    Incident reports           No fleet     none identified   * Health and Safety     Quality of Services
                                                                                          Standard Care Environment and           Unlikely (2)   Manager                      ERIC return                cleaning                       Reports to Governance   (inc S4BH) Action
                                            Annual Health Check - Quality of Services -




                                                                                          Amenities Domain                        =              Health & Safety Group        Premises Audit             programme                      and Board               Plan          HSE




                                                                                                                                                                                                                                                                                            Director of Finance and Performance
                                                                                                                                  Significant    Estates Manager              Internal Audit reviews.    for 2008/09                    *Estates Reports to     Inspection Action
                                                Compliance with Core Standards




                                                                                                                                                 Local Counter Fraud          Compliance Assurance       No Security                    Board *Audit            Plan Infection
                                                                                                                                                 Specialist                   Reports                    Management                     Committee Assurance     Control Action Plan
                                                                                                                                                 Fleet Manager                Risk Assessments           Policy No                      Reports to Board (inc   Fleet Cleaning
                                                                                                                                                 VEUW Group Compliance        Counter Fraud Policy       Fleet Policy                   LCFS)                   Programme Security




                                                                                                                                                                                                                                                                                                                                  Governance
              GOV 235
AF/19/08




                                                                                                                                                 Assurance Audits             Health & Safety Manual                                    *VUEWG Minutes to       Management Policy
                                                                                                                                                 Internal Audit Reviews       (policies)                                                Governance              Fleet Policy
                                                                                                                                                 Information Governance       Estate Strategy and                                       *Compliance
                                                                                                                                                 Manager                      Programme                                                 Assurance Reports
                                                                                                                                                                              ICT Security Policy                                       *Information
                                                                                                                                                                              JRCALC Guidelines on                                      Governance Reports to
                                                                                                                                                                              Privacy                                                   Governance and Board
                                                                                                                                                                              Information Governance
                                                                                                                                                                              Policy




                                                                                                                                                                                                                                                                                            Acute Services Associate Director
                                                                                          Sustain compliance with Core            High (5) x     Head of PR and Strategic     Joint major incident       none         none identified *Public Health Board      Quality of Services
                                                       Annual Health Check - Quality of
                                                       Services - Compliance with Core




                                                                                          Standard Public Health Domain           Unlikely (2)   Communications               exercises.                 identified                   Reports                   (inc S4BH) Action
                                                                                                                                  =              Acute Services Associate     Compliance Assurance                                    *Employee Health          Plan
                                                                                                                                  Significant    Director                     Reports                                                 Board Reports
                                                                                                                                                 Health, Safety & Security    Public Health Strategy                                  *Compliance




                                                                                                                                                                                                                                                                                                                                  Governance
                                                                  Standards
              GOV 235
AF/20/08




                                                                                                                                                 Manager                      Health Promotion for                                    Assurance Reports
                                                                                                                                                 Resilience Manager           Employees Strategy                                      *Resilience Reports to
                                                                                                                                                                              Major Incident Plan                                     Board




                                                                                          Achieve the existing national targets   Significant Performance Improvement         Performance Improvement    none         none identified *Operational              Quality of Services
                                   Annual Health Check
              CL O49 and OPS 209




                                                                                          (Category A, B, and Thrombolysis)       (4) x        Plan and Group                 Plan Reports               identified                   Performance Reports       (inc S4BH) Action
                                     National Targets




                                                                                                                                                                                                                                                                                            Chief Executive
                                                                                                                                  Unlikely (2) Clinical Effectiveness Group   Compliance Assurance                                    to Board                  Plan




                                                                                                                                                                                                                                                                                                                                  Directors
AF/21/08




                                                                                                                                  =                                           Reports                                                 *Compliance
                                                                                                                                  Significant                                                                                         Assurance Reports
                                                                                                                                  High (5) x
                                                                                                                                  Unlikely (2)
                                                                                                                                  =
                                                                                                                                  Significant




                                                                                                                                                                                                                                                          Version 5.0 February 2009 Board
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            Risk                                                                                                                                                               Gaps in




                                                                                                                                                                                                                                                                                                                   Group
                                                                                                            Risk




                                                                                                                                                                                                                                                                         Role
                                                                                                                                                     Positive Assurances on                  Gaps in                               Other Action/ Action
Ref        Register     Type                                                     Objective                               Key controls/ systems                                 Controls/                      Measurement
                                                                                                           Rating                                            Controls                       Assurance                                     Plans
             Ref                                                                                                                                                               Systems


                                                                   Achieve the new national targets      High (5) x Monitoring of compliance by Compliance Assurance          none         none identified *Compliance Report to Quality of Services




                                                                                                                                                                                                                                                                         Head of PR and Strategic Communications
                            Annual Health Check National Targets


                                                                                                         Unlikely (2) Directors' Team           Reports                       identified                   Board on release of   (inc S4BH) Action
                                                                                                         =                                                                                                 targets               Plan
                                                                                                         Significant




                                                                                                                                                                                                                                                                                                                   Directors
              GOV 272
AF/22/08




                                                                   Implement the recommendations within Significant    Performance Improvement Minutes from Groups            none         none identified *Assurance Reports to Performance
                        National Targets/




                                                                   Taking Healthcare to the Patient     (4) x          Plan Group         Better                              identified                   Board from Better     Improvement Plan




                                                                                                                                                                                                                                                                         Chief Executive
                                                                                                        Unlikely (2)   Value, Better Care                                                                  Value, Better Care
                            Guidance




                                                                                                                                                                                                                                                                                                                   Directors
AF/23/08


              OPS 177




                                                                                                        =              Committee                                                                           Committee
                                                                                                        Significant




                                                                                                                                                                                                                                                               Director of Urgent Care and Clinical
                                                                   Implement the Mental capacity Act     Moderate      JRCALC Guidelines 2006       JRCALC Guidelines 2006    none         none identified Mental Capacity Act     Training to be
                                                                   2005                                  (3) x         detail appropriate action to available to all staff.   identified                   KPIs                    delivered to all
                            National Targets/ Guidance




                                                                                                         Moderate      be taken when assessing                                                                                     operational staff
                                                                                                         (3) =         mental capacity.                                                                                            during 2008/09 and
                                                                                                         Significant   Senior Manager with                                                                                         monitored by




                                                                                                                                                                                                                                                                                                                   Governance
                                                                                                                       specialist knowledge of                                                                                     Directors Team and




                                                                                                                                                                                                                                                                             Services
AF/24/08


              CL 280




                                                                                                                       Mental Capacity Act 2005 in                                                                                 Governance
                                                                                                                       post                                                                                                        Committee.
                                                                                                                                                                                                                                   KPIs to be developed




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            Risk                                                                                                                                                         Gaps in




                                                                                                                                                                                                                                                                                                    Group
                                                                                                Risk




                                                                                                                                                                                                                                                                       Role
                                                                                                                                           Positive Assurances on                         Gaps in                                Other Action/ Action
Ref        Register     Type                                        Objective                                Key controls/ systems                                       Controls/                          Measurement
                                                                                               Rating                                              Controls                              Assurance                                      Plans
             Ref                                                                                                                                                         Systems


                                                      Safeguarding Children 2006            Significant Safeguarding Policy              Safeguarding Reports          none             none identified *Clinical Performance No specific action




                                                                                                                                                                                                                                                             Director of Urgent Care and
                         National Targets/ Guidance


                                                                                            (4) x        Safeguarding Manager                                          identified                       Board Reports         plan
                                                                                            Unlikely (2)                                                                                                *Safeguarding Reports




                                                                                                                                                                                                                                                                  Clinical Services
                                                                                            =                                                                                                           to Governance




                                                                                                                                                                                                                                                                                                    Governance
                                                                                            Significant
AF/25/08


              CL 281




                                                      Implementation of the Health Act 2006 Signficant     Infection Control Strategy    Infection Control Action Plan none             none identified Infection Control action Infection Control




                                                                                                                                                                                                                                                             Director of Urgent Care and Clinical
                                                      (Hygiene Code)                        (4) x          and Policy (revised in 07/08)                               identified                       plan updates to          Action Plan
                                                                                            Moderate       Compliance with Hygiene                                                                      Governance
                         National Targets/ Guidance




                                                                                            (3) =          Code in 2007/08
                                                                                            Significant




                                                                                                                                                                                                                                                                                                    Governance
                                                                                                                                                                                                                                                                           Services
AF/26/08


              CL 282



                         National Targets/ Guidance




                                                      Compliance with the Civil             High (5) x     Pandemic Flu Plan.         Membership of National           Business         Business        *Reports on Major or     Business Continuity
                                                      Contingencies Act 2004 including      Unlikely (2)   Fallback plans for A&E and Ambulance Working Group          Continuity       Continuity      Adverse Incidents        Plans for all functions
                                                      Business Continuity Plans             =              PTS Control          Board and local Resilience Forums      Plans            Plans outside   *Audit reports




                                                                                                                                                                                                                                                                       Chief Executive
                                                                                            Significant    approved Major Incident                                     outside A&E      A&E and PTS     *Review of Major




                                                                                                                                                                                                                                                                                                    Directors
AF/27/08


              EP 259




                                                                                                           Plan                                                        and PTS          Controls        Incident Plans
                                                                                                                                                                       Controls and
                                                                                                                                                                       responsibility
                                                                                                                                                                       to be
                                                                                                                                                                       allocated




                                                                                                                                                                                                                                                                       Chief Executive
                                                      Prepare for the Olympiad in 2012 in                  Project Manager appointed     5 year secondment agreed      none             none identified Reports from Project     Olympiad Project
                                                      Weymouth                                                                           for Resilience Manager to     identified                       Lead       Notes from    Plan
                       Guidance




                                                                                                                                                                                                                                                                                                    Directors
AF/28/08




                       National
                       Targets/




                                                                                                                                         be Olympics Project Lead                                       project group




                                                                                                                                                                                                                           Version 5.0 February 2009 Board
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                                                                                                                                Progress to Date
                              Group                                                                                                        Quarter 4
           Topic
Ref




                                                                          Jan                                                                     Feb                                 Mar


                                           Directors 7th January: Performance Management Strategy              Directors 3rd February: Estates - Acorn building update; Adverse
                                           approved.      Governance Committee 8th January: Corporate and Weather report; Appraisals update. FT Steering Committee 12th
                                           Communications Strategy approved ; CAD Governance and Data          February 2009: FT Budget; 2009/10 Commissioning update
                                           Quality update ; Internal Audit Report - First Responders ; Fire
                                           and Rescue Service MOU for Co-Responders report ; ARP progress
                                           verbal report. Directors 21st January: Consultation Master Log
           Corp Objective 1




                                           update; Strategy Day planning discussion. Board Meeting 29th
AF/01/08




                              Directors




                                           January: Procurement Strategy annual review ratified;
                                           Communications Strategy annual review ratified; HR Activity
                                           Update (including workforce, recruitment, sickness, appraisals);
                                           Corporate Performance Report; ICT Service performance report;
                                           Performance Management Strategy approved; Finance Strategy
                                           approved; Operational Plan development document (including budget
                                           setting, capital plan, CRES); PTS review update; Estates (including
                                           capital plan, waste management, environment); Winter Pressures


                                           Directors Meeting 7th January: Data Quality data handling review;   Directors 3rd February: Estates - Acorn building update; Annual
                                           Travel Policy annual review approved; Procurement Strategy annual   Health Check lapse score report; Risk Register Corporate and
                                           review approved; Performance Management Strategy approved;          Directors reviewed; New Risks Identified: weather warnings;
                                           Risk Register corporate and directors' ; NHSLA Level 1 Assessment   Adverse Weather report; Agenda for Change job matching update:
                                           Report. Governance Committee 8th January: NHSLA Level 1             Healthcare Commission infection control inspection update;
                                           Assessment Report; Corporate and Communications Strategy            Appraisals update. Audit Committee 5th February: Audit
                                           approved; Patient Safety and Quality Action Plan and dashboard      Commission progress report; Internal Audit interim report and action
                                           update; Patient Experience Quarterly report; Corporate              plan. Counter Fraud interim report; ALE interim audit report;
                                           Manslaughter Action Plan update; Serious Untoward Incident          Losses and Compensations Register; IFRS briefing paper; Audit
                                           update; Incident (including medication) report; Central Alert       Committee self assessment; Internal Audit Process report; Risk
                                           (safety) System report; Risk Management Training Plan update ;      Register Corporate and Directors risk registers; Information
                                           Infection Prevention and Control update ; Implementation of         Governance update.      FT Steering Committee 12th February:
                                           National Clinical Guidelines ; Medicines Policy Implementation      Draft Governance Rationale report; FT Risk Register; Training
                                           Plan update ; Clinical Performance Indicators update ; Clinical     and Events Logbook and Event Debrief.
                                           Audit and Research update ; Information Governance update ;
                                           Health and Safety Action Plan update ; Protocol for Non
                                           Controlled Drugs Procedures trials verbal report.
           Corp Objective 2

                              Governance
AF/02/08




                                                                                                                                      Page 14 of 21                                         Version 4.0 December Gov
                              Group
           Topic
Ref




                                                                           Jan                                                                    Feb                              Mar


                                           Angioplasty/Reperfusion Criteria mapping exercise verbal report ;
                                           Assurance Framework Governance responsibilities ; Policy Register
                                           Governance responsibilities ; Policy Audit Update ; Annual Health
                                           Check update ; S4BH compliance with 2 standards report ; Risk
                                           Management Group final minutes ; Risk Register Corporate and
                                           Directors ; Safeguarding report (Baby 'P') ; CAD Governance and
           Corp Objective 2




                                           Data Quality update ; Internal Audit Report - First Responders ;
                              Governance
AF/02/08




                                           Internal Audit Recommendations - Controlled Drugs verbal report -
                                           Fire and Rescue Service MOU for Co-Responders report ; New
                                           Risks - none identified ; at this meeting ; LFEG assurance report
                                           ; VEUW Group minutes ; Joint Air Ambulance minutes ; Clinical
                                           Effectiveness minutes ; New Legislation - Health and Safety
                                           Offences Act identified for consideration. Directors 21st January:
                                           Strategy Day planning report; Data Quality update; Patient Safety
                                           & Quality Dashboard; Health and Safety Offences Act update;
                                           Health and Safety Executive action plan;


                                           Annual Health Check 2008/09 schedule; FT Governance System
                                           report; New Risks Identified: Conflict resolution training and H&S
                                           Offences Act.     Board Meeting 29th January: Procurement
                                           Strategy annual review ratified; Communications Strategy annual
                                           review ratified; Counter Fraud Policy and Guidance annual review
                                           ratified; HR Activity Update (including workforce, recruitment,
                                           sickness, appraisals); Corporate Performance Report; Patient
                                           Experience quarterly report; Serious Untoward Incident annual
                                           update; ICT Service performance report; Security Management
                                           annual update; Use of Resources (ALE) interim audit report;
                                           Infection Control update; Care Quality Commission registration
                                           compliance report; FoI Publication Scheme update; Operational
                                           Plan development document (including budget setting, capital plan,
                                           CRES); Estates (including capital plan, waste management,
                                           environment); Strategic Partnership proposal; Annual Health
                                           Check schedule; Winter Pressures; Information Governance
                                           update

                                           Governance Committee 8th January: Corporate and                      Directors 3rd February: Adverse Weather report
           Corp Objective 3




                                           Communications Strategy approved ; CAD Governance and Data
AF/03/08




                              Directors




                                           Quality update. Directors 21st January: Corporate Performance
                                           Report. Board Meeting 29th January: Communications
                                           Strategy annual review ratified . Performance Management
                                           Strategy approved; Winter Pressures

                                           Governance Committee 8th January: HR activity update ;                 Directors 3rd February: Agenda for Change job matching update;
           Corp Objective 4




                                           Appraisals verbal update; Protocol for Non Controlled Drugs            Appraisals update; Leadership and Management Development
AF/04/08




                              Directors




                                           Procedures trials verbal update ; CAD Governance and Data              Programme update
                                           Quality update. Board Meeting 29th January: HR Activity Update
                                           (including workforce, recruitment, sickness, appraisals); Care Quality
                                           Commission registration compliance report; HR Review




                                                                                                                                      Page 15 of 21                                      Version 4.0 December Gov
                              Group
           Topic
Ref




                                                                                        Jan                                                                     Feb                              Mar


                                                       FT Steering Committee 12th January: Monitor income
                              FT Steering Committee




                                                       consultation document discussed. Directors 21st January:
           Corp Objective 5




                                                       Corporate Performance Report. Board Meeting 29th January:
AF/05/08




                                                       Corporate Performance Report; Operational Plan development
                                                       document (including budget setting, capital plan, CRES); FT Steering
                                                       Committee assurance report and minutes



                                                       Directors 7th January: Staff Survey action plan. Governance         Directors 3rd February: Occupational Health Policy reviewed;
                                                       Committee 8th January: Corporate and Communications                 Appraisals update
                              Equality and Diversity
           Corp Objective 6




                                                       Strategy approved ; Patient Experience Quarterly report ; HR
                                                       activity update ; Appraisals verbal update. Directors 21st January:
AF/06/08




                                                       Corporate Performance Report; Flexi-time proposal. Board
                                                       Meeting 29th January: Communications Strategy annual review
                                                       ratified; HR Activity Update (including workforce, recruitment,
                                                       sickness, appraisals); Corporate Performance Report; Patient
                                                       Experience quarterly report

                                                       Board Meeting 29th January: Corporate Performance Report;
           Corp Objective 7




                                                       Estates Report (including capital plan, waste management,
AF/07/08




                              Directors




                                                       environment)




                                                       Directors 7th January: Making Experience Count conference              Directors 3rd February: Making Experience Count and financial
                                                       details ; NHSLA Level 1 Assessment Report. Governance                  redress report; Appraisals update. Audit Committee 5th February:
                                                       Committee 8th January: Corporate and Communications                    Company Secretary role assessment;    FT Steering Committee
                                                       Strategy approved ; Patient Experience Quarterly report ; NHSLA        12th February: Market Assessment and Perceptions audit interim
                                                       Level 1 Assessment Report ; Corporate Manslaughter Action Plan         report.
                                                       update ; Health and Safety Action Plan update ; CAD Governance
                                                       and Data Quality update ; Internal Audit Report - First
           Corp Objective 8




                                                       Responders ; Fire and Rescue Service MOU for Co-Responders
                                                       report ; New Legislation - Health and Safety Offences Act identified
AF/08/08




                              Directors




                                                       for consideration. Directors 21st January: Corporate Performance
                                                       Report; Patient Safety & Quality Dashboard; New Risks
                                                       Identified: Conflict resolution training and H&S Offences Act. Board
                                                       Meeting 29th January: Communications Strategy annual review
                                                       ratified. HR Activity Update (including workforce, recruitment,
                                                       sickness, appraisals); Corporate Performance Report; Patient
                                                       Experience quarterly report; Olympics annual project update;
                                                       Strategic Partnership proposal




                                                                                                                                                    Page 16 of 21                                      Version 4.0 December Gov
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           Topic
Ref




                                                                                         Jan                                                                     Feb                             Mar


                                                          Directors 7th January: Minutes of previous meeting approved ;        Directors 3rd February: Minutes of previous meeting approved.
                                                          Wyvern Health minutes for information. Governance Committee          Audit Committee 5th February: Company Secretary role
                                                          8th January: Minutes of Previous Meeting approved; Corporate         assessment; Minutes of Previous Meeting approved. FT Steering
                                                          and Communications Strategy approved ; CAD Governance and            Committee 12th February: Minutes of previous meeting approved
                                                          Data Quality update. FT Steering Committee 12th January:
                                                          Minutes of Previous Meeting approved. Directors 21st January:
           Statutory duties




                                                          Consultation Master Log update; Leadership and Team
AF/09/08




                                                          Development programme update; Productive Leader programme
                                  Audit




                                                          update; Annual Report timetable update. Board Meeting 29th
                                                          January: Communications Strategy annual review ratified;
                                                          Counter Fraud Policy and Guidance annual review ratified; Standing
                                                          Orders/SFIs annual review approved; Minutes of Previous Meeting
                                                          approved; Audit Committee assurance report and minutes; FT
                                                          Steering Committee assurance report and minutes; Governance
                                                          Committee assurance report and minutes; Risk Management
                                                          Training for Board
                                                          FT Steering Committee 12th January: Board development tool           FT Steering Committee 12th February: FT Steering Committee
           Board development




                                                          feedback workshop undertaken. Board Meeting 29th January: FT         Finance Development session; FT Essential Reading List
AF/10/08




                                                          Steering Committee assurance report and minutes; Risk
                                  Audit




                                                          Management Training for Board




                                                          Governance Committee 8th January: Corporate Manslaughter             Audit Committee 5th February: Knowledge, Training and
                                                          Action Plan update ; Health and Safety Action Plan update ; Risk     Mechanism Review - self assessment; Minutes of previous
           Governance reporting




                                                          Management Process Review update ; New Legislation - Health          meeting approved.  FT Steering Committee 12th February: FT
                                                          and Safety Offences Act identified for consideration ; Meeting       Risk Register.
                                  Governance
AF/11/08




                                                          reflection at end of Committee. Directors 21st January: Patient
                                                          Safety & Quality Dashboard; New Risks Identified: Conflict
                                                          resolution training and H&S Offences Act. Board Meeting 29th
                                                          January: Procurement Strategy annual review ratified; Audit
                                                          Committee assurance report and minutes ; Governance Committee
                                                          assurance report and minutes

                                                          Directors 7th January: Foundation Trust Network minutes ;            Directors 3rd February: FT interim market assessment report;
                                                          Governance Committee 8th January: Corporate and                      FT draft governance rationale; FT private patient income. FT
                                                          Communications Strategy approved . FT Steering Committee 12th        Steering Committee 12th February: Draft Governance Rationale
                                                          January: Minutes of Previous Meeting approved ; Marketing            report; FT Risk Register; Market Assessment and Perceptions
                                  FT Steerign Committee




                                                          discussed ; Market assessment tender process update ; Draft          audit interim report; FT Budget; NHS South West update; Monitor
                                                          constitution discussed but not presented ; SHA feedback update ;     Board Minutes; UNISON PPI update; Training and Events
           FT Project
AF/12/08




                                                          Draft Involvement Strategy discussed ; Draft Communications          Logbook and Event Debrief; AFT Leads Group Minutes; FTN
                                                          Strategy discussed ; FT Risk Register reviewed ; Monitor income      newsletters; FT Essential Reading List
                                                          consultation document discussed ; Board development tool
                                                          feedback workshop undertaken. Directors 21st January:
                                                          Consultation Master Log update; FT Governance System report.
                                                          Board Meeting 29th January: FT update; Communications
                                                          Strategy annual review ratified; FT Steering Committee assurance
                                                          report and minutes




                                                                                                                                                     Page 17 of 21                                     Version 4.0 December Gov
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           Topic
Ref




                                                                                                 Jan                                                                       Feb                          Mar


                                                                 Governance Committee 8th January: Corporate Manslaughter
           New legislation




                                                                 Action Plan update ; Infection Prevention and Control update ;
AF/13/08




                                                    Directors




                                                                 Implementation of National Clinical Guidelines ; New Legislation
                                                                 - Health and Safety Offences Act identified for consideration.
                                                                 Directors 21st January: Health and Safety Offences Act update

                                                                 Directors 7th January: Risk Register corporate and directors' to       Directors 3rd February: Risk Register Corporate and Directors
                                                                 Directors; NHSLA Level 1 Assessment Report . Governance                reviewed; New Risks Identified: weather warnings
                                                                 Commttee 8th January: Corporate Manslaughter Plan update ;
                                                                 Serious Untoward Incident update ; Incident (including meds
                                                                 report ; Central Alert System report ; Risk Management Training
                                                                 Plan update ; Infection Control update ; Implementation of NICE
                                                                 Guidelines ; Medicines Policy Implementation Plan update ; H&S
                                                                 Action Plan update ; NHSLA Level 1 Assessment Report ; Risk
                                                                 Management Group final minutes ; Risk Register Corporate and
                                                                 Directors ; Safeguarding report (Baby 'P') ; Internal Audit
             S4BH - safety




                                                                 Recommendations - Controlled Drugs verbal report ; New Risks -
                                                    Governance
AF/14/08




                                                                 none identified at this meeting ; LFEG assurance report ; VEUW
                                                                 Group minutes ; Joint Air Ambulance minutes ; Clinical
                                                                 Effectiveness minutes ; New Legislation - H&S Offences Act
                                                                 identified for consideration. Directors 21st January: Patient Safety
                                                                 & Quality Dashboard; New Risks Identified: Conflict resolution
                                                                 training and H&S Offences Act.


                                                                 Board Meeting 29th January: Serious Untoward Incident annual
                                                                 update; Security Management annual update Serious Untoward
                                                                 Incident annual update; Security Management annual update;
                                                                 Infection Control Update; Care Quality Commission registration
                                                                 compliance report; Medical Transport Service update

                                                                 Directors 7th January: NHSLA Level 1 Assessment Report.               Directors 3rd February: Adverse Weather report; Healthcare
             S4BH - Clinical / cost effectiveness




                                                                 Governance Committee 8th January: Implementation of                   Commission infection control inspection update
                                                                 National Clinical Guidelines ; Clinical Performance Indicators
                                                                 update ; Clinical Audit and Research update ; Health and Safety
                                                                 Action Plan update ; NHSLA Level 1 Assessment Report. Directors
                                                    Governance
AF/15/08




                                                                 21st January: Patient Safety & Quality Dashboard; New Risks
                                                                 Identified: Conflict resolution training and H&S Offences Act.. Board
                                                                 Meeting 29th January: Winter Pressures




                                                                                                                                                               Page 18 of 21                                  Version 4.0 December Gov
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           Topic
Ref




                                                                              Jan                                                                       Feb                                 Mar


                                               Directors 7th January: Performance Management Strategy                Directors 3rd February: Making Experience Count and financial
                                               approved ; Risk Register corporate and directors' ; Making            redress report; Risk Register Corporate and Directors reviewed; New
                                               Experience Count conference details ; NHSLA Level 1 Assessment        Risks Identified: weather warnings; Occupational Health Policy
                                               Report. Governance Committee 8th January: Minutes of                  reviewed; Leadership and Management Development
                                               Previous Meeting approved; Patient Safety and Quality Action          Programme update. Audit Committee 5th February: Audit
                                               Plan and Dashboard update ; Patient Experience Quarterly report ;     Commission progress report. Internal Audit interim report and action
                                               Corporate Manslaughter Action Plan update ; Serious Untoward          plan; ALE interim audit report; Company Secretary role assessment;
                                               Incident update ; Incident (including medication) report ; Central    Internal Audit Process report; Knowledge, Training and
           S4BH - governance




                                               Alert (safety) System report ; Risk Management Training Plan          Mechanism Review - self assessment; Information Governance
                                  Governance
AF/16/08




                                               update ; Clinical Performance Indicators update ; Clinical Audit      update.     FT Steering Committee 12th February: Draft
                                               and Research update ; HR activity update ; Appraisals verbal          Governance Rationale report; FT Risk Register.
                                               update ; Information Governance update ; Health and Safety
                                               Action Plan update ; Protocol for Non Controlled Drugs
                                               Procedures trials verbal report ; NHSLA Level 1 Assessment
                                               Report; Angioplasty/Reperfusion Criteria mapping exercise
                                               verbal report ; Assurance Framework Governance responsibilities ;
                                               Policy Register Governance responsibilities ; Policy Audit Update ;
                                               LFEG assurance report.



                                               Annual Health Check update ; S4BH compliance report ; Risk
                                               Management Process Review update ; RM Group final minutes ;
                                               Risk Register Corporate and Directors ; Safeguarding report (Baby
                                               'P') ; Audit Report - First Responders ; Audit Recommendations -
                                               Controlled Drugs report ; Fire and Rescue Service MOU report ;
                                               New Risks - none identified at this meeting ; VEUW Group
                                               minutes ; Joint Air Ambulance minutes ; Clinical Effectiveness
           S4BH - governance




                                               minutes ; New Legislation - H&S Offences Act identified for
                                               consideration. Directors 21st January: Strategy Day planning
                                  Governance
AF/16/08




                                               update; Patient Safety and Quality Dashboard; Flexi-time
                                               proposal; FT Governance System report; New Risks: Conflict
                                               resolution training and H&S Offences Act.. Board Meeting 29th
                                               January: Procurement Strategy review ratified; Counter Fraud
                                               Policy review ratified; Patient Experience quarterly report; Use of
                                               Resources (ALE) interim audit report; SO/SFIs annual review
                                               approved; HR Review; Annual Health Check schedule;
                                               Governance Committee assurance report and minutes; Information
                                               Governance update



                                               Directors 7th January: Making Experience Count conference          Directors 3rd February: Making Experience Count and financial
           S4BH - patient focus




                                               details ; NHSLA Level 1 Assessment Report. Governance              redress report;
                                  Governance




                                               Committee 8th January: Corporate and Communications
AF/17/08




                                               Strategy approved ; Patient Experience Quarterly report ; NHSLA
                                               Level 1 Assessment Report ; S4BH compliance with 2 standards
                                               report ; LFEG assurance report. Board Meeting 29th January:
                                               Patient Experience quarterly report; FoI Publication Scheme update




                                                                                                                                            Page 19 of 21                                         Version 4.0 December Gov
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           Topic
Ref




                                                                                                                                                                                                     Jan                                                                   Feb                           Mar


                                                                                                                                                                       Directors 7th January: Making Experience Count conference        Directors 3rd February: Making Experience Count and financial
           AHC - new national targets AHC - existing targets S4BH - public health S4BH - care environment/ amenities S4BH - accessible/ responsive care




                                                                                                                                                                       details. Governance Committee 8th January: Corporate and         redress report;
                                                                                                                                                                       Communications Strategy approved ; Patient Experience Quarterly
                                                                                                                                                                       report. Board Meeting 29th January: Patient Experience quarterly
                                                                                                                                                                       report
                                                                                                                                                          Governance
AF/18/08




                                                                                                                                                                       Directors 7th January: NHSLA Level 1 Assessment Report.
                                                                                                                                                                       Governance Committee 8th January: Corporate and
                                                                                                                                                                       Communications Strategy approved ; NHSLA Level 1 Assessment
                                                                                                                                                                       Report ; Corporate Manslaughter Action Plan update ; Infection
                                                                                                                                                                       Prevention and Control update ; Internal Audit Report - First
                                                                                                                                                          Governance
AF/19/08




                                                                                                                                                                       Responders ; Fire and Rescue Service MOU for Co-Responders
                                                                                                                                                                       report. Board Meeting 29th January: Security Management
                                                                                                                                                                       annual update; Infection Control Update; Care Quality
                                                                                                                                                                       Commission registration compliance report




                                                                                                                                                                       Governance Committee 8th January: Patient Experience
                                                                                                                                                                       Quarterly report. Board Meeting 29th January: Patient
                                                                                                                                                          Governance




                                                                                                                                                                       Experience quarterly report
AF/20/08




                                                                                                                                                                       Governance Committee 8th January: Corporate and                  Directors 3rd February: Annual Health Check lapse score report
                                                                                                                                                                       Communications Strategy approved ; Internal Audit Report - First
                                                                                                                                                                       Responders ; Fire and Rescue Service MOU for Co-Responders
AF/21/08




                                                                                                                                                          Directors




                                                                                                                                                                       report. Directors 21st January: Corporate Performance Report;
                                                                                                                                                                       Annual Health Check 2008/09 schedule. Board Meeting 29th
                                                                                                                                                                       January: Corporate Performance Report; Performance
                                                                                                                                                                       Management Strategy approved

                                                                                                                                                                       Governance Committee 8th January: Clinical Performance           FT Steering Committee 12th February: FT Budget
                                                                                                                                                                       Indicators update. Directors 21st January: Corporate
                                                                                                                                                                       Performance Report. Board Meeting 29th January: Corporate
                                                                                                                                                                       Performance Report; Performance Management Strategy
AF/22/08




                                                                                                                                                          Directors




                                                                                                                                                                       approved




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                                                                                                                                                                             Jan                                                                 Feb                            Mar


                                                                                                                                               Directors 7th January: CRES workshop discussion. Governance         FT Steering Committee 12th February: Market Assessment and
           Olympiad Civil contingencies act Hygiene code Safeguarding children Mental capacity act Taking healthcare to patient




                                                                                                                                               Committee 8th January: Corporate and Communications                 Perceptions audit interim report
                                                                                                                                               Strategy approved ; Internal Audit Report - First Responders ; Fire
                                                                                                                                               and Rescue Service MOU for Co-Responders report. Directors
AF/23/08




                                                                                                                                  Directors




                                                                                                                                               21st January: CRES assurance report. Board Meeting 29th
                                                                                                                                               January: Performance Management Strategy approved;
                                                                                                                                               Strategic Partnership proposal




                                                                                                                                               No new updates in January
                                                                                                                                  Governance
AF/24/08




                                                                                                                                               Directors 7th January and Governance Committee 8th January:
                                                                                                                                               NHSLA Level 1 Assessment Report; Safeguarding report (Baby
                                                                                                                                  Governance




                                                                                                                                               'P') to Governance Committee only. Board Meeting 29th January:
AF/25/08




                                                                                                                                               Governance Committee assurance report and minutes




                                                                                                                                               Directors 7th January and Governance Committee 8th January:
                                                                                                                                  Governance
AF/26/08




                                                                                                                                               NHSLA Level 1 Assessment Report. Board Meeting 29th
                                                                                                                                               January: Infection Control update; Care Quality Commission
                                                                                                                                               registration compliance report; Governance Committee assurance
                                                                                                                                               report and minutes
                                                                                                                                               Board Meeting 29th January: Olympics annual project update;
                                                                                                                                               Pandemic Flu planning update summary
AF/27/08




                                                                                                                                  Directors




                                                                                                                                               Board Meeting 29th January: Olympics annual project update       FT Steering Committee 12th February: Market Assessment and
AF/28/08




                                                                                                                                  Directors




                                                                                                                                                                                                                Perceptions audit interim report




                                                                                                                                                                                                                                     Page 21 of 21                                    Version 4.0 December Gov

								
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