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					     Portsmouth City Teaching PCT - Commissioning Assurance Framework and Strategic Risk Register
                                                                                                                                                                                                                                                                                              Cross References
     Reference   Date        Strategic Risk Description of Risk                              Controls in Place               Assurances          RL RI    Residual Responsible     Gaps in Control        Action          Expected     AP      Gaps in     Action    Expected         AP      S4BH     UoR         NHSLA   Other   Change Note
                                                                                                                                                          Risk     Director                               Planned         Implementati Cross   Assurance   Planned   Implementation   Cross
                                                                                                                                                          Score                                                           on Date      Ref                           Date             Ref
     08-C-018    6/27/2008   Meet key NHS        Failure to meet targets would risk poor     Operational Plan;               Regular            4     5   20       Innes                                                                                                                      C18,     1.2, 1.3                      ↑
                             (& Operational      health care service for patients at point   Performance monitoring;         Performance                           Richens,                                                                                                                   C19, C7f
                             Plan) targets       of need leading to loss of good opinion     Contracts with service          Reporting to the                      Director of
                                                 and confidence of stakeholders and          providers;                      Board (I/P);                          Strategy &
                                                 increased performance management            Demand management               Contract                              System
                                                 by SHA                                      action plans – ISTC,            monitoring reports                    Management
                                                                                             Independent Contractors,        (I/P);
                                                                                             OoH;                            STIES reporting
                                                                                             Integrated Care Pathways.       (I/P).




     09-C-007    8/6/2009    To ensure that      Local residents will die and/or suffer      National, Regional and Local    Major Incident       4   5   20       Dr Paul         Still some             Working with                                                                                                             new
                             NHS                 harm because essential and critical         standard Emergency              Plans including                       Edmondson-      ineffective or         Directors to
                             Portsmouth is       services for people suffering from          Planning structures and         Pandemic Flu                          Jones,          absent business        ensure plans
                             able to lead and    Pandemic Flu or those with other            processes that are well         Plan.                                 Director of     continuity plans for   are in place.
                             coordinate the      serious clinical conditions are             rehearsed and exercised         Board approval for                    Public Health   corporate &
                             planning for, the   insufficient or ineffective.                                                major incident and                    & Wellbeing     commissioning
                             preparation for,                                                National, Regional and Local    pandemic Flu                                          directorates
                             the response to     Local healthcare organisations will fail    Pandemic Flu specific plans     Plans and regular
                             and the             to meet mission critical and business       and processes that have         Emergency
                             recovery from       essential targets and patient safety,       been well rehearsed and         Planning Updates
                             the current         financial balance and organisational        exercised.                      provided to Board
                             Influenza           performance will be compromised and                                         Gold, Silver and
                             Pandemic in a       suffer.                                     Effective, well tried local     Bronze Command
                             safe, effective                                                 systems and processes in        Structure in place
                             and timely                                                      place to jointly identify and   and working well.
                             manner.                                                         minimise risks to               National Pandemic
                                                                                             organisations, services and     Flu Service, local
                                                                                             individuals across the health   Antiviral Collection
                                                                                             economy.                        Points and other
                                                                                                                             systems and
                                                                                                                             processes also in
                                                                                                                             place and working
                                                                                                                             well.
                                                                                                                             Business
                                                                                                                             Continuity Plans
                                                                                                                             well developed
                                                                                                                             across most areas
                                                                                                                             of healthcare
                                                                                                                             provision including
                                                                                                                             secondary care,
                                                                                                                             community care
                                                                                                                             and primary care.




     08-C-004    6/16/2008   To deliver a        Failure to provide appropriate use of       Community Hospital Sub-         PCT Board receipt 4      4   16       Pam Hobbs,                                                                                                         OP 10.11 C7d,    1.1, 2.1, 5.8       OP:       ↑
                             Community           resources to meet patient and political     committee;                      of OBC & SOC                          Executive                                                                                                                   C7f,    3.2                 5.3.6
                             Hospital            expectations and provide effective          OBC;                            May08 (I/P);                          Programme                                                                                                                   C20a,
                             (Healthcare         healthcare leading to unwarranted           SOC;                            PCT Board receipt                     Director (New                                                                                                               C20b,
                             campus) on St.      financial expenditure and patient           Project Plan;                   of Community                          patterns of                                                                                                                 C22c
                             Mary’s site by      disatisfaction.                             Performance Management          Hospital Sub-                         provision) /
                             2011.                                                           by DoH/SHA;                     committee minutes                     Debbie
                                                                                                                             on a regular basis                    Tarrant,
                                                                                                                             (I/P)                                 Director of
                                                                                                                                                                   Primary Care




     08-C-013    6/16/2008   To ensure           Failure to achieve financial targets and    Signed Service Level            Board discussion 4       4   16       Martin          1 Identification of    1. Quarterly    1. Wef Apr 09                                                       C7a&c,   1.1, 1.2,                     ↑
                             sound financial     return required surplus level will impact   Agreements;                     of Finance Reports                    Wilkinson,      risk to finances in    meetings                                                                            C7d      1.3
                             delivery in year    on future management of the PCT and         Finance Reports;                at each meeting                       Acting Director each service area      between Gov
                             and recurrent       opportunities made available to the         Audit Committee;                (I/P);                                of Finance                             Team &
                             financial           PCT.                                        External / Internal Audit of    Audit Committee                                                              Directors
                             balance                                                         Financial arrangements.         consideration of
                             together with                                                                                   audit reports (I/P).
                             other financial
                             duties.




Commissioner                                                                                                                                                                             1 of 8                                                                                                                                          1 September 2009
     Portsmouth City Teaching PCT - Commissioning Assurance Framework and Strategic Risk Register
                                                                                                                                                                                                                                                                                         Cross References
     Reference   Date        Strategic Risk Description of Risk                            Controls in Place                Assurances          RL RI   Residual Responsible   Gaps in Control     Action           Expected     AP      Gaps in      Action    Expected         AP      S4BH     UoR        NHSLA      Other     Change Note
                                                                                                                                                        Risk     Director                          Planned          Implementati Cross   Assurance    Planned   Implementation   Cross
                                                                                                                                                        Score                                                       on Date      Ref                            Date             Ref
     08-C-020    6/27/2008   Manage          Overheat of acute contracts would lead        Service Provider contracts       Demand              4   4   16       Innes                                                                                                                   C7d,     1.3, 2.2              OP 8.4      ↑
                             demand across to financial pressures on the PCT.              and monitoring;                  Management                           Richens,                                                                                                                C7f,
                             all acute                                                     Monthly demand monitoring        action plan                          Director of                                                                                                             C17,
                             contracts to                                                  via all contracts;               reporting (I/P);                     Strategy &                                                                                                              C18,
                             ensure it                                                     Financial contingency            Performance                          System                                                                                                                  C19,
                             remains within                                                planning;                        notice issued for                    Management                                                                                                              C22a,
                             agreed activity                                               Operational Plan;                data (PHT) (I/P).                                                                                                                                            C22c
                             plans                                                         Joint strategy for Health &
                                                                                           Social Care of Older People;
                                                                                           Joint commissioning unit
                                                                                           proposed with Portsmouth
                                                                                           City Council;
                                                                                           Capacity map;
                                                                                           CE system group.




     09-C-004    4/20/2009   Develop,          The PCT as a Commissioner has the           HCC Surveys and other            Board             4     4   16       Rob Dalton,   1. Communications                                OP 14.5 WCC report                               OP 9.10 C17                            OP 14.1     ↑
                             establish and     legal requirement to ensure effective       surveys;                         consideration and                    Director of   & Engagement                                             identifying
                             maintain an       engagement processes. WCC                   Portsmouth LINk;                 approval of                          Corporate     Strategy                                                 improvement
                             engagement        standards require delivery to a certain     Overview & Scrutiny Panel        Commissioning                        Affairs
                             infrastructure    standard. The PCT may not have the          (OSP);                           and Operational                                    2. Board                                                                                                  C8b,     3.3
                             that supports     resource, infrastructure or expertise to    Public Involvement &             Plans Spring 2009                                  Development                                                                                               C11c
                             effective         deliver against the requirements            Communications Manager;          (I/P);                                             Programme
                             commissioning     leading to potential poor                   Patient Experience Team;         OSP regular                                        3. Staff achieving                                                                                        C11a     3.3                   OP 14.7
                             of services.      commissioning and reputational              Public Health needs              quarterly report                                   Masters in
                                               issues.                                     analysis;                        (I/P);                                             Commissioning
                                                                                           Commissioning Plan;              Survey report to                                   qualification
                                                                                           Operational Plan;                IGC 2008 (I/P).                                    4. WCC             Autumn 2009                                                                            C22a&c   2.1, 3.2
                                                                                           Organisational Development                                                          assessment 09/10
                                                                                           Plan;
                                                                                           Communications &
                                                                                           Engagement Strategy
                                                                                           2008/09;


     09-C-006      5/12/2009 Introduction of   Failure to implement national criteria at   Review of national criteria                          4   4   16       Innes         1. CCC Project      Establish by                                                                                                         OP 8.4    new
                             new national      a local level in a timely manner may        being conducted locally;                                              Richens,      Group               end of June
                             continuing care   result in delays in continuing care         Financial impact                                                      Director of                       2009
                             criteria for      reviews. Financial impact of new            assessment;                                                           Strategy &
                             children.         criteria on PCT allocations for             Dedicated manager and                                                 System
                                               continuing care.                            team for continuing care.                                             Management


                                                                                                                                                                               2. Impact           Conduct and
                                                                                                                                                                               assessment          report to PEC
                                                                                                                                                                                                   within 2
                                                                                                                                                                                                   months of
                                                                                                                                                                                                   publication of
                                                                                                                                                                                                   national
                                                                                                                                                                                                   criteria

     08-C-001    Apr-08      Safe & legal      Failure to meet/prepare for needs of        Integrated Governance            Training statistics 4   3   12       Rob Dalton,                                                                                                             C5d,     2.3, 2.4   Standard 1 OP:         -    Recommendation
                             operation of      patients and statutory duties in a timely   Committee and Audit              presented to IGC                     Director of                                                                                                             C7a&c                          4.9.6,           by RD to de-
                             organisation      manner causing exposure to legal            Committee examining              (I/P);                               Corporate                                                                                                                                              5.3.7,           escalate to
                                               claim and the potential to harm             emerging issues and              Governance and                       Affairs                                                                                                                                                5.4.5            directorate risk
                                               patients.                                   current duties on a regular      Patient Safety                                                                                                                                                                                               register following
                                                                                           basis;                           domain reports to                                                                                                                                                                                            reports to IGC on
                                                                                           Contract for Legal Advice;       IGC on a quarterly                                                                                                                                                                                           S4BH, UoR and
                                                                                           Bevan Brittan Legal              basis (I/P);                                                                                                                                                                                                 the project report
                                                                                           Placement undertook              Workshop to                                                                                                                                                                                                  to Ops Board
                                                                                           exercise to identify potential   assess evidence &                                                                                                                                                                                            regarding
                                                                                           gaps Sept 2008;                  assurance for                                                                                                                                                                                                Performance
                                                                                           Training Needs Analysis          MCA/DoLs on                                                                                                                                                                                                  Accelerator
                                                                                           identifying mandatory            12/3/09 (I/P);
                                                                                           training by staff group;         MCA 2005 Annual
                                                                                           S4BH annual assessment;          Report approved
                                                                                           UoR annual assessment.           by Operational
                                                                                                                            Board May 2009
                                                                                                                            (I/P)




Commissioner                                                                                                                                                                       2 of 8                                                                                                                                               1 September 2009
     Portsmouth City Teaching PCT - Commissioning Assurance Framework and Strategic Risk Register
                                                                                                                                                                                                                                                                                                Cross References
     Reference   Date        Strategic Risk Description of Risk                               Controls in Place               Assurances          RL RI    Residual Responsible Gaps in Control       Action          Expected     AP      Gaps in         Action       Expected          AP    S4BH     UoR         NHSLA    Other   Change Note
                                                                                                                                                           Risk     Director                          Planned         Implementati Cross   Assurance       Planned      Implementation Cross
                                                                                                                                                           Score                                                      on Date      Ref                                  Date              Ref
     08-C-009    6/16/2008   Consistent and     Availability of corporate and patient         Information Goverance           Information          3   4   12       Pam Hobbs,                                                             1. Judgement    1. Report to 1. October 09 IGC       C5d,     2.2, 2.4, 1.8, 4.4             -
                             effective          records is an issue for PCT                   Toolkit assessment;             Governance                            Executive                                                              from Healthcare IGC when     2. October 09 IGC       C5b, C9, 3.3
                             records            commissioning, legality and ongoing           Information Governance &        Toolkit scores                        Programme                                                              Commission      received                             C13c,
                             management         patient care. May lead to poor patient        Records Development             reported to IGC                       Director (New                                                          assessment      2. Take to                           C16
                                                care and failed delivery of services.         Manager post; Records           Mar 09 (I/P);                         patterns of                                                            2008/09         IGC & Audit
                                                                                              Audit 2007/08;                  NHSLA Level 1                         provision)                                                             2. BDO RM       Committee
                                                                                              Records Management              assessment                                                                                                   audit report;
                                                                                              Policy, Safe Haven Policy,      outcome 2009
                                                                                              Information Security Policy,    (E/P);
                                                                                              Subject Access Guidance,        Bulk Data Transfer
                                                                                              Freedom of Information          Action Plan Report
                                                                                              Policy;                         to IGC Jul 08 (I/P);
                                                                                              Records Management Audit        Records
                                                                                              BDO 2008;                       Management Audit
                                                                                              Bulk Data Transfer review       outcome and
                                                                                              2008 and ongoing;               action plan to IGC
                                                                                              Records Management              (I/P);
                                                                                              training at corporate           Completed GAP
                                                                                              induction;                      13/08 (I/P).
                                                                                              Healthcare Commission
                                                                                              assessment;

     08-C-010    6/16/2008   Ensure PCT         Failure to manage corporate and               Data Protection Policy,         Information          3   4   12       Pam Hobbs,                                                             1. Judgement    1. Report to 1. October 09 IGC       C1a, C9, 2.2, 2.4, 1.8, 4.4             -
                             information is     patient records may give rise to breach       Information Security Policy,    Governance                            Executive                                                              from Healthcare IGC when                             C13b,    3.3
                             held, processed    of patient/staff confidentiality leading to   Internet and Email Policies,    Toolkit scores                        Programme                                                              Commission      received                             C13c,
                             and disposed of    loss of stakeholder confidence,               Records Management              2008/09 (I/P);                        Director (New                                                          assessment                                           C16
                             securely           adverse media coverage and potential          Policy, Subject Access          NHSLA Level 1                         patterns of                                                            2008/09;
                                                litigation                                    Guidelines;                     assessment                            provision)
                                                                                              Information Governance          outcome 2009
                                                                                              Toolkit assessment;             (E/P);
                                                                                              Records Development             Bulk Data Transfer
                                                                                              Manager post;                   Action Plan Report
                                                                                              IG Co-ordinators;               to IGC Jul 08 (I/P);
                                                                                              Records Audit 2007/08;          Completed GAP
                                                                                              Records Management Audit        13/08 (I/P).
                                                                                              BDO;
                                                                                              Bulk Data Transfer review;
                                                                                              Records Management
                                                                                              training;
                                                                                              Healthcare Commission
                                                                                              assessment;
                                                                                              On-site shredding facilities;
                                                                                              IPHIS team;
                                                                                              Training;




     08-C-011    6/16/2008   Implementation     Resource needs during phases of               PCT attendance at key           Quarterly report to 3    4   12       Pam Hobbs,    1. New Informatics 1. Currently     Jul-09                                                                    C9,      2.1, 2.2, -                    -
                             of Connecting      development may impact on PCT                 meetings and regular liaison    PCT Chair and                         Executive     Strategy           under                                                                                      C13c,    3.2
                             for Health         finances and delivery of appropriate          with southern cluster and       Local IT                              Programme                        development                                                                                C16
                             agenda             systems.                                      SHA to influence direction;     Deployment Board                      Director (New
                                                                                              Informatics Strategy 2005-      (I/P);                                patterns of
                                                                                              2008;                           Individual reports                    provision)
                                                                                              Board lead;                     on each system to
                                                                                              Local IT Deployment Board ;     Local IT
                                                                                              IT business case process;       Deployment Board
                                                                                                                              (I/P);
                                                                                                                              PCT Business
                                                                                                                              Plan quarterly
                                                                                                                              report to the Board
                                                                                                                              (I/P).

     08-C-012    6/16/2008   Provide suitable   Sub-standard premises may be                  Capital programme and           Regular PEAT        3    4   12       Pam Hobbs,                                                                                                                  C20a,    3.2         3.1                -
                             21st century       provided which could impact on                plan;                           reports (I/P);                        Director of                                                                                                                 C20b,
                             accommodation      service delivery and patient/staff safety     Estates Strategy 2003-          Backlog                               Finance &                                                                                                                   C21,
                             for                leading to potential litigation and sub-      2008;                           maintenance                           Support                                                                                                                     C7d
                             commissioned       optimal PCT development.                      SSDP;                           statistics (I/P);                     Services
                             services,                                                        PEAT inspections.               Consideration of
                             maintaining                                                                                      key risk issues
                             estate/premises                                                                                  such as ligature
                             used for                                                                                         points (I/P).
                             patients and
                             staff to
                             adequate
                             standards.

     09-C-005    4/20/2009   Ensure effective   The PCT must continue to comply with          S4BH process & domain           ‘A’ rated Business 3     4   12       Rob Dalton,     1. Confirm        Review                      OP                                                            C7a&c    2.2, 2.3,                      -
                             governance,        legal and national requirements and           reports;                        Assurance                             Director of     requirements of   Manual and                  14.13                                                                  2.4
                             accountability     ensure transparency in decision               UoR process;                    Framework (by                         Corporate       Integrated        emerging
                             and decision       making and effective record keeping to        NHSLA Group;                    SHA 08/09) (E/P);                     Affairs         Governance        regional and
                             making             prevent failures with possible public         Integrated Governance           NHSLA Level 1                                         Manual            national
                             processes          loss of confidence, clinical risk,            Committee;                      March 2009 (E/P);                                                       requirements
                             during             reduced quality, reduced patient              AF&SRR & GAP;                   UoR Level 2 April                                                       by Sep 09
                             organisational     safety, reputational risk and legal           Business Services support       2009 (E/P).                                           2. Integrated     Develop by                  OP                                                            c7a&c
                             change             challenge.                                    to first level Board                                                                  Governance        Oct 2009                    14.14
                                                                                              committees;                                                                           Strategy
                                                                                              Business Pro-forma &                                                                  3. Improve       Complete                     WCC AP                                                        C22a&c
                                                                                              related materials.                                                                    adherence to WCC WCC actions
                                                                                                                                                                                    requirements     from review by
Commissioner                                                                                                                                                                              3 of 8     Mar 2010                                                                                                                               1 September 2009
     Portsmouth City Teaching PCT - Commissioning Assurance Framework and Strategic Risk Register
                                                                                                                                                                                                                                                                                                 Cross References
     Reference   Date        Strategic Risk Description of Risk                            Controls in Place               Assurances         RL RI    Residual Responsible     Gaps in Control     Action           Expected      AP     Gaps in           Action     Expected          AP      S4BH     UoR        NHSLA       Other    Change Note
                                                                                                                                                       Risk     Director                            Planned          Implementati Cross   Assurance         Planned    Implementation    Cross
                                                                                                                                                       Score                                                         on Date       Ref                                 Date              Ref
     08-C-005    5/23/2008   Maintain culture   Risk Management arrangements that          Board and committee             IGC minutes to      2   5   10       Rob Dalton,     1. Directorate Risk 1. Structured    1. wef Apr 09        1. Judgement of 1. Report to 1. November 09            C7a&c,   2.3, 2.4   Standards   OP:        -    Recommendation
                             of risk            fail to meet the needs of the PCT          structure;                      each PCT Board                       Director of     Register reviews. quarterly                               Healthcare      IGC when     IGC                       C7b,                1& 3        5.4.1,          by RD to de-
                             management to      would present the possibility of           PCT strategies and policies;    (I/P);                               Corporate                           meetings in                           Commission      received     2. November 09            C1a                             5.4.5           escalate to
                             ensure effective   patient/staff harm which could lead to     Assurance Framework &           NHSLA Level 1                        Affairs                             place with                            2008/09;        2. Report to IGC                                                                       directorate risk
                             governance         litigation and damage to patient           Strategic Risk Register         2009 (E/P);                                                              Directorates &                        2. Outcome of IGC when                                                                                 register following
                             arrangements       confidence in the PCT and the PCT's        (AF&SRR);                       ALE assessment                                                           Gov Team                              UOR 2008/09     received                                                                               reports to IGC on
                             and provide a      reputation.                                Integrated Governance           outcome 2007/08 -                                                                                              assessment;                                                                                            S4BH
                             safe                                                          Committee (IGC) rolling         Level 2 (E/P);                                                                                                                                                                                                        and UoR and
                             environment                                                   agenda;                         PCT Board                                                                                                                                                                                                             creation of new
                                                                                           Domain reports;                 minutes Nov 08                                                                                                                                                                                                        issues ref 09-C-
                                                                                           Risk management related         showing risks                                                                                                                                                                                                         005
                                                                                           posts;                          reported and
                                                                                           Standards for Better Health     discussed (I/P);
                                                                                           assessment 2008/09;             Reporting of SAEs
                                                                                           Performance Accelerator;        and SUIs to each
                                                                                           UoR assessment 2008/09.         Part 2 Board (I/P).




     08-C-015    6/27/2008   Provide clean &    Clinical areas that may not be clean       Modern Matron led Infection     Regular Safety and 3    3   9        Paul                                                                      1. Healthcare     1. Report to 1. October 09           C1b,     2.1, 3.1   2.7, 2.8,              -
                             hygienic           (within PCT Provider arm and other         Control Advisory Group;         PH domain reports                    Edmondson-                                                                Commission        IGC when     2. July 09              C4a,                3.7, 4.9
                             environment        service providers) may give raise to       Compliance monitoring of        to IGC                               Jones,                                                                    judgement         received                             C4b,
                             and equipment      patient/staff infection which could lead   Soft FM Contract;               (I/P);                               Director of                                                               2008/09;          2. Report to                         C4c,
                             for patients,      to litigation and poor publicity.          Decontamination Group;          PEAT reports                         Public Health                                                             2. Infection      Board                                C21
                             staff and                                                     Infection Control Service       (I/P);                               & Wellbeing                                                               Control Service
                             stakeholders.                                                 SLA and monitoring;             Infection Control                                                                                              Annual Report
                                                                                           Waste management                update to Board                                                                                                2008/09.
                                                                                           contract for independent        Jan 2008 (I/P);
                                                                                           contractors;                    PEC, Board, IGC
                                                                                           Infection Control Policies;     minutes (I/P).
                                                                                           Monitoring of PHT MRSA
                                                                                           cases;
                                                                                           Staff mandatory training
                                                                                           TNA;
                                                                                           Healthcare Commission
                                                                                           assessment 07/08;
                                                                                           Infection Control Action
                                                                                           Plan;
                                                                                           PEAT reviews;
                                                                                           Decontamination Policy;
                                                                                           Medical Devices Policy;
                                                                                           NHSLA Level 1 2009.



     08-C-016    6/27/2008   Commission       Inadequate service provision for             Dental Action Plan;             Report against     3    3   9        Debbie          1. Dental           1.To follow    1. Summer                                                                     C17,     2.1, 2.2                          -
                             safe and         patients may cause ill health, poor          Dental survey;                  Dental Action Plan                   Tarrant,        Commissioning       survey results 2009                                                                          C18,
                             effective Dental perception of PCT.                           Dental Outreach Centre,         (Board Nov 2007)                     Director of     Strategy.                                                                                                        C19,
                             Services                                                      King’s Outreach Service;        (I/P).                               Primary Care                                                                                                                     C23
                             including Out of                                              Hampshire PCT contract
                             Hours and                                                     and monitoring;
                             emergency                                                     Identification of poorly
                             dental services                                               resourced areas (e.g
                                                                                           Paulsgrove).

     08-C-017    6/27/2008   Continue to       Inability to maximise opportunities to      Operational Plan;               SHA feedback       3    3   9        Debbie                                                                                                                           C7d,     1.1, 2.1               OP 8.4     ↓
                             improve           provide excellent patient care.             PEC;                            (E/P);                               Tarrant,                                                                                                                         C17,
                             relationship with                                             TARGET;                         LMC feedback                         Director of                                                                                                                      C22a,
                             independent                                                   Practice Based                  (E/P).                               Primary Care                                                                                                                     C22c,
                             contractors                                                   Commissioning;                                                                                                                                                                                        C23
                             together guiding                                              Performance management
                             the                                                           by SHA;
                             modernisation
                             of health service
                             provision


     08-C-021    6/27/2008   Provide and        Harm to patients, staff or PCT where       Training Calendar;              Minutes of IGC,     3   3   9        Ros Jack,                                                                 1. Healthcare     1. Report to 1. October 09           C5b,     3.3, 2.4   Standard 2 OP 14.6     -
                             ensure uptake      appropriate training is not available or   Training statistical reports;   Ops Board, PEC                       Director of                                                               Commission        IGC when                             C5c,
                             of mandatory       undertaken possibly resulting in           Learning & Development          and Board                            Workforce &                                                               judgement         received                             C5d,
                             training           increased litigation and poor publicity.   Strategy;                       discussing training                  Development                                                               2008/09                                                C11b,
                                                                                           Learning & Development          issues                                                                                                                                                                C11c
                                                                                           Department;                     (I/P);
                                                                                           Standards for Better Health     Regular domain
                                                                                           Assessment 2007/08;             reporting of
                                                                                           Operational Plan &              training statistics
                                                                                           Performance report;             (I/P).
                                                                                           Local L&D training matrices.
                                                                                           NHSLA Level 1 2009




Commissioner                                                                                                                                                                         4 of 8                                                                                                                                                     1 September 2009
     Portsmouth City Teaching PCT - Commissioning Assurance Framework and Strategic Risk Register
                                                                                                                                                                                                                                                                                        Cross References
     Reference   Date        Strategic Risk Description of Risk                            Controls in Place               Assurances         RL RI    Residual Responsible   Gaps in Control   Action    Expected     AP      Gaps in         Action       Expected            AP      S4BH     UoR         NHSLA      Other      Change Note
                                                                                                                                                       Risk     Director                        Planned   Implementati Cross   Assurance       Planned      Implementation      Cross
                                                                                                                                                       Score                                              on Date      Ref                                  Date                Ref
     08-C-025    11-Aug-08   Ensure good          Not implementing effective systems for   Training in NHS number on       Service reviews     3   3   9        Innes                                                                                                                   C7a&c,   1.2, 1.3,                           -
                             quality activity     collection, monitoring and reporting     PAS;                            (I/P);                               Richens,                                                                                                                C16,     2.2
                             data and             could lead to incorrect representation   IG toolkit assessment;          Key performance                      Director of                                                                                                             C18,
                             management           of PCT services or commissioning         Operational Plan;               indicators (I/P);                    Strategy &                                                                                                              C19
                             information is       profiles against targets. Services may   Internal / External Audits of   SLA rebasing (I/P).                  System
                             available in         not be commissioned or managed           data quality;                                                        Management
                             relation to PCT      effectively.                             SWIFT/PAS Integration,
                             provider                                                      CASH system, SMS
                             services                                                      system;
                                                                                           Head of Informatics post;
                                                                                           IT Deployment Board;
                                                                                           Strategic Plan from IT
                                                                                           Deployment Board;
                                                                                           Healthcare wide scheduling;
                                                                                           Performance management
                                                                                           meetings at directorate and
                                                                                           individual service levels.




     08-C-007    5/23/2008   Support              Ineffective communications will cause    Mechanisms for key              SHA                2    4   8        Rob Dalton,                                                    1 SHA           1. Present to 1. August 09               C6, C17 1.1, 1.3, 4.2, 5.10                  -    Recommendation
                             effective internal   mixed messages to stakeholders and       scrutiny including              communications                       Director of                                                    communications IGC                                               2.1, 3.2                                  by RD to de-
                             and external         may damage PCT reputation and            Healthcare Commission and       performance                          Corporate                                                      performance                                                                                                escalate to
                             communications       progress with/appropriateness of PCT     OSP;                            matrix (E/P);                        Affairs                                                        matrix received                                                                                            directorate risk
                             and maintain         developments                             Communications Team;            Regular CHiP                                                                                        by IGC on an                                                                                               register.
                             relationships                                                 Staff Involvement Forum;        assessment                                                                                          annual basis
                             with stakeholder                                              City Brief;                     findings (E/P);
                             groups                                                        Website;                        Internal
                                                                                           Documents and leaflets;         Communications
                                                                                           Four Quarters events;           Survey Report to
                                                                                           Annual report;                  IGC Aug'09 (I/P)
                                                                                           CHiP assessment;
                                                                                           Communications &
                                                                                           Engagement Strategy
                                                                                           2008/09;
                                                                                           Patient Information Policy;
                                                                                           Intranet live from 30 Jan
                                                                                           2009;
                                                                                           Internal Communications
                                                                                           Survey 09

     08-C-008    5/25/2008   Have a               Full adherence to procedures must be     Medical Devices policy;         Response to SABs 2      4   8        Rob Dalton,                                                    1. Judgement of 1. Report to 1. October 09 IGC           C1b,     2.4         2.7, 3.7                -    Recommendation
                             framework in         in place to prevent risk of harm to      Medical Devices SLA with        on CAS website                       Director of                                                    Healthcare      IGC when                                 C4a,                                              by RD to reduce
                             place within         patients and staff and increased         PHT and monitoring              (E/P);                               Corporate                                                      Commission      received                                 C4b,                                              likelihood and
                             which the Board      potential for litigation.                arrangements;                   NHSLA level 1                        Affairs                                                        assessment                                               C4c,                                              close issue
                             may be assured                                                CAS Alert system;               assessment 2009                                                                                     2008/09;                                                 C4e, C5a                                          (following report
                             that there is                                                 Healthcare Commission           (E/P).                                                                                                                                                                                                         to panel by Katie
                             safe and                                                      assessment;                                                                                                                                                                                                                                    Hovenden & IGC
                             effective                                                     Domain reports to IGC;                                                                                                                                                                                                                         review of S4BH
                             management of                                                 Decontamination Policy;                                                                                                                                                                                                                        declaration in
                             medical                                                                                                                                                                                                                                                                                                      April 09) once
                             devices.                                                                                                                                                                                                                                                                                                     SABs
                                                                                                                                                                                                                                                                                                                                          investigation
                                                                                                                                                                                                                                                                                                                                          completed.



     08-C-006    5/23/2008   Meet public and      Services not commissioned to meet        HCC Surveys and other           Board              2    3   6        Rob Dalton,   Stakeholder                                                                                               C17,     1.1, 1.3, 4.2, 5.10    OP 5.2.7     -
                             patient              public expectations in terms of demand   surveys;                        consideration and                    Director of   management                                                                                                C22a,    3.2
                             involvement          and requirements of local health         Portsmouth LINk;                approval of                          Corporate     arrangements                                                                                              C22c
                             agenda               community and delivering expectations    Overview & Scrutiny Panel       Commissioning                        Affairs
                                                  of the World Class Commissioning         (OSP);                          and Operational
                                                  agenda.                                  Patient Experience Team         Plans Spring 2009
                                                                                           (Complaints & PALS) and         (I/P);
                                                                                           reports;                        Minutes of
                                                                                           Public Health needs             committees
                                                                                           analysis;                       discussing outline
                                                                                           Commissioning Plan;             business cases
                                                                                           Operational Plan;               (I/P);
                                                                                           Business Planning process;      Receipt of
                                                                                           Organisational Development      Quarterly
                                                                                           Plan;                           Performance
                                                                                           Capital Programme;              Reports at Board
                                                                                           Hampshire and Isle of           (I/P);




Commissioner                                                                                                                                                                      5 of 8                                                                                                                                                 1 September 2009
     Portsmouth City Teaching PCT - Commissioning Assurance Framework and Strategic Risk Register
                                                                                                                                                                                                                                                                        Cross References
     Reference   Date        Strategic Risk Description of Risk                          Controls in Place            Assurances      RL RI    Residual Responsible     Gaps in Control   Action    Expected     AP      Gaps in     Action    Expected         AP      S4BH    UoR        NHSLA   Other   Change Note
                                                                                                                                               Risk     Director                          Planned   Implementati Cross   Assurance   Planned   Implementation   Cross
                                                                                                                                               Score                                                on Date      Ref                           Date             Ref
     08-C-014    6/27/2008   Reducing health   Failure to design and deliver             PH Directorate budget        Annual Report of 2   3   6        Paul                                                                                                            C22a,   2.1, 3.2   5.8               -
                             inequalities      appropriate and effective interventions   planning;                    the Director of                   Edmondson-                                                                                                      C22b,
                             across            to improve health in deprived             PCT Operational plan and     Public Health                     Jones,                                                                                                          C22c,
                             Portsmouth        communities and other vulnerable          performance monitoring;      (Board Nov’08)                    Director of                                                                                                     C23,
                             City.             population groups.                        Overview & Scrutiny Panel;   (I/P);                            Public Health                                                                                                   C17
                                                                                         Patient Experience &         Performance                       & Wellbeing
                                                                                         Communications Team;         Report to Board
                                                                                         Local Area Agreement.        (I/P);
                                                                                                                      PH Quarterly
                                                                                                                      Report to PEC
                                                                                                                      (I/P);
                                                                                                                      Choosing Health &
                                                                                                                      Vascular
                                                                                                                      Prevention
                                                                                                                      Programme Board
                                                                                                                      minutes (I/P);
                                                                                                                      Health & Social
                                                                                                                      Wellbeing
                                                                                                                      Partnership Board
                                                                                                                      minutes (I/P);
                                                                                                                      Safer Portsmouth
                                                                                                                      Partnership
                                                                                                                      minutes (I/P);
                                                                                                                      LSP Minutes
                                                                                                                      Overview &
                                                                                                                      Scrutiny Panel
                                                                                                                      minutes (I/P).




                                                                                                                      I - Internal
                                                                                                                      E - External
                                                                                                                      P - Positive
                                                                                                                      N - Negative




Commissioner                                                                                                                                                                6 of 8                                                                                                                               1 September 2009
Portsmouth City Teaching PCT - Provider Arm Assurance Framework and Strategic Risk Register
                                                                                                                                                                                                                                                                                                   Cross References
Reference   Date        Strategic Risk Description of Risk                             Controls in Place               Assurances          RL RI   Residual Responsible      Gaps in Control       Action         Expected     AP          Gaps in         Action      Expected            AP      S4BH      UoR        NHSLA       Other    Change Note
                                                                                                                                                   Risk     Director                               Planned        Implementati Cross       Assurance       Planned     Implementation      Cross
                                                                                                                                                   Score                                                          on Date      Ref                                     Date                Ref
09-P-002    4/16/2009   Implementation Financial cost of new system and                Project team                    Report on           5   4   20       Judy Hillier,    1. Analysis of                                                                                                        C6        1.1,1.2,                          -
                        of RIO (Clinical potential problems with staff ‘buying-in’     Project plan                    progress to                          Director of      impact on staff                                                                                                                 2.2, 3.3
                        system)          to new system causing an impact on            Monitoring reports to IT        Operational Board                    Clinical &       time during
                                         clinical staff time in terms of training      Deployment Group                on a regular basis.                  Community        implementation &
                                         and ongoing usage.                            Board/Corporate support                                              Services         use driving action
                                                                                                                                                                             planning to support
                                                                                                                                                                             process.

                                                                                                                                                                             2. Communications                                                                                                     C17, C6
                                                                                                                                                                             plan

                                                                                                                                                                             3. Workforce plan                                                                                                     C6,
                                                                                                                                                                                                                                                                                                   C11a, b
09-P-003    4/16/2009   Transforming        Failure to meet the strategic intention    Project governance              Project             3   5   15        Pam Hobbs,    1. Staff change                                                 1. Hosting                                                                               OP 9.7     -
                        Community           of the Commissioner and failing to         arrangements include:           documentation;                        Executive     policy                                                          discussion
                        Services - a        meet the national timetable, business      Project management;             Options appraisal                     Programme                                                                     paper
                        major               continuity during change process           Project plan;                   report;                               Director (New
                        organisational      leading to potential patient safety        Consultation strategy (staff    Record of legal                       patterns of
                        change              issues, public misconception of            and other stakeholders);        meetings.                             provision)
                        programme           changes and adherence to legal             Legal advice available.
                        affecting the       requirements irrespective of staffing,
                        whole PCT and       notably type, and competition and co-
                        over two            operation guidance.
                        thousand staff
                        in the provider
                        function.

08-P-002    Apr-08      Provision of        Lack of Social Workers (employed by        Social Care Professional        Workforce           4   3   12        Judy Hillier,   1. Pay review         Underway                                1.Evidence of   1. Report to 1. IGC August 09           C6,       2.1        Standards              -    Recommendation
                        effective care to   Portsmouth City Council) causing           Lead in PCT;                    numbers / training                    Director of                                                                   minimum safe    IGC                                     C22a,                4&5                         by JH to de-
                        mental health       breakdown in care pathway and delays       Integrated Mental Health        statistics                            Clinical &                                                                    coverage        minimum                                 C22c                                             escalate to
                        patients            in assessment resulting in staff,          Team;                           presented regularly                   Community                                                                                     safe                                                                                     Directorate Risk
                                            service and client risk.                   S75 Partnership meetings;       to DMT (I&E/P)                        Services                                                                                      coverage                                                                                 register once IGC
                                                                                       Membership of AMH Assoc.                                                                                                                                            satistical                                                                               receives a report
                                                                                       Dir in Portsmouth City                                                                                                                                              information                                                                              on s75
                                                                                       Council DMT;
                                                                                       ASW / Social Workers
                                                                                       using PCT AER forms.


08-P-003    Apr-08      Ensure good         1) Not implementing effective systems      Training in NHS number on       Presentation of     3   4   12        Judy Hillier,   1. Community          IT team        Summer 2009                                                                      C16,      1.3, 2.2   -                      -    Recommendation
                        quality activity    for collection, monitoring and reporting   PAS;                            audits to Audit                       Director of     system must be        researching                                                                                     C7a&c,                                           by JD to reduce
                        data and            could lead to incorrect representation     IG toolkit annual               Committee 2008                        Clinical &      made available        options with                                                                                    C18                                              score and close.
                        management          of PCT services or commissioning           assessment;                     (E/P);                                Community                             Lead                                                                                                                                             New issue ref 09-
                        information is      profiles against targets. Services may     Operational Plan;               Outcome of                            Services                              Clinicians                                                                                                                                       P-002 takes up
                        available           not be commissioned or managed             Internal / External Audits of   significant systems                                                                                                                                                                                                          main issue
                                            effectively.                               data quality;                   failure tests (IT
                                                                                       SWIFT/PAS Integration,          contingency
                                                                                       CASH system, SMS                arrangements)repo
                                                                                       system;                         rted to Deployment
                                                                                       Head of Informatics post;       Board (I/P);
                                                                                       IT Deployment Board;            Performance
                                                                                       Strategic Plan from IT          Report to
                                                                                       Deployment Board.               Operational Board
                                                                                                                       on a regular basis
                                                                                                                       (I/P).




08-P-023    8/12/2008   Provide             Gaps in the knowledge of staff who         Mental Health Medicines      Audit findings (I/P). 4    3   12        Judy Hillier,   1 Planning for        1. Potential   1. Summer     1.                                                                 C3, C4d, 2.4, 3.3    4.6                    -    JH advises that a
                        appropriate         handle medicines, in terms of technical    Management Group;                                                     Director of     replacement of        Post(s)        2009          Operatio                                                           C23                                              contingency plan
                        medicines           knowledge and understanding of             Principal Pharmacist Post in                                          Clinical &      Principal             redesign and                 nal Plan                                                                                                            is in place with
                        management          systems and legal requirements, may        Mental Health;                                                        Community       Pharmacist in         Business                     4.8.3                                                                                                               Lloyds
                        support within      call patient safety and legality into      Audit activity by Principal                                           Services        Mental Health         Case                                                                                                                                             Pharmacist
                        the Provider        question leading to increased              Pharmacist;                                                                           (1-4)                                                                                                                                                                  covering.
                        Services            possibility of harm and litigation.        Service Level Guidelines                                                                                                                                                                                                                                     Recommend
                        Directorate.                                                   and Protocols;                                                                                                                                                                                                                                               reducing
                                                                                       Care and Control of                                                                                                                                                                                                                                          likelihood to 3
                                                                                       Medicines Policy;                                                                                                                                                                                                                                            and de-escalating
                                                                                       Controlled Drugs Policy;                                                                                                                                                                                                                                     to directorate risk
                                                                                       Non-Medical Prescribing                                                                                                                                                                                                                                      register.
                                                                                       Policy.




Provider                                                                                                                                                                                7 of 8                                                                                                                                                             1 September 2009
Portsmouth City Teaching PCT - Provider Arm Assurance Framework and Strategic Risk Register
                                                                                                                                                                                                                                                                                             Cross References
Reference   Date        Strategic Risk Description of Risk                                 Controls in Place             Assurances        RL RI    Residual Responsible      Gaps in Control       Action    Expected     AP      Gaps in             Action       Expected         AP      S4BH    UoR        NHSLA        Other   Change Note
                                                                                                                                                    Risk     Director                               Planned   Implementati Cross   Assurance           Planned      Implementation   Cross
                                                                                                                                                    Score                                                     on Date      Ref                                      Date             Ref
08-P-024    8/12/2008   Appropriate           Adverse events exacerbated through           AD commissioning report on    Service review 3       4   12       Judy Hillier,                                                                                                                   C1a,    2.1, 3.3   Standard 2             -    JH advises
                        residential AMH       insufficient available staff with high use   internal improvement issues   reports (I/P);                      Director of                                                                                                                     C5b,                                           budgets have
                        services staffing     of locum staff impacting on continuity       in respect of rota            MHA Commission                      Clinical &                                                                                                                      C11b,                                          been realigned
                        establishment.        of care, PCT procedural awareness            management, wellness,         reports (I/P).                      Community                                                                                                                       C11c                                           with £300k
                                              and financial resources.                     budget redistribution and                                         Services                                                                                                                                                                       moving to
                                              Potential for staff and patient harm         benchmarking with a                                                                                                                                                                                                                              residential. E-
                                              leading to litigation.                       consequent gap analysis;                                                                                                                                                                                                                         rostering tool
                                                                                           Continuous Improvement                                                                                                                                                                                                                           coming on line.
                                                                                           Plan;                                                                                                                                                                                                                                            Recommend de-
                                                                                           AER/SAE reporting and                                                                                                                                                                                                                            escalating.
                                                                                           Root Cause Analysis;
                                                                                           Clinical governance
                                                                                           reporting to CSPSC;
                                                                                           Standards for Better Health
                                                                                           Domain Reporting;
                                                                                           Available locum cover;
                                                                                           Mental Health Act
                                                                                           Commission reviews;
                                                                                           Service review process;
                                                                                           Staff sickness absence
                                                                                           data.

09-P-001    4/16/2009                                                                      Clinical Audit Manager        Report on audit    3   4   12        Judy Hillier,   Guidance on action                                   Annual report on    Planned                               C5d,                                      -
                        Suitable and                                                       Audit Group with terms of     programme                            Director of     planning following                                   clinical audit to   submission                            C14c
                        sufficient clinical   Lack of evidence of outcomes from            reference                     progress to                          Clinical &      and audit written                                    Operational         Summer
                        audit within          front line to PCT Board giving potential     Audit database                Operational Board                    Community       and incorporated in                                  Board               2009
                        Portsmouth            for poor audits, failure to identify         Audit training                on a regular basis                   Services        training
                        Mental Health &       correct audit programme, poor patient        Agreed audit programme
                        Community             outcomes and missed opportunities for        Monitoring reports to
                        Services.             learning and improvement.                    CSPSC



                                                                                                                         I - Internal
                                                                                                                         E - External
                                                                                                                         P - Positive
                                                                                                                         N - Negative




Provider                                                                                                                                                                                 8 of 8                                                                                                                                                    1 September 2009