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					                                     2009/10                                                                                           BOARD ASSURANCE FRAMEWORK                                                                                                                     Appendix 1
                                                                                                                                             As at 03 March 2010

                                                                          Delivered by (date)

                                                                                                                                                                                                                                                                                                               WCC competency
  Lead Director

                                                                                                                                                                                 Control A/I/U
                                     Strategic objective                                                Description of risk                                                                                                  ASSURANCE                                                                                           Code
                                                                                                                                        What controls have you put in place
                                                                                                            Risk rating                                                                             Gaps In Control     Sources of Assurance                               Action                                                Amber
                                                                                                                                        to ensure delivery of this objective?
                                    Steps to achievement                                                  Consequence                                                                                                         (indicate                                                                                          Green
                                                                                                           x Likelihood                                                                                                      +ve or -ve)                                                                                        & status

                  Strategic objective 1
                  To refresh the Strategic Plan reflecting the outcomes of consultation with local people, Joint Strategic Needs Assessment, Lambeth's Sustainable Community Strategy, Healthcare for London, South East London Acute Service Strategy and
                  to take forward year three of the plan though the development and agreement of an Operating Plan for 2010/2011
                                                                                                                                                                                                                                                    2010/11 Operating Plan submitted to NHS London by

                                                                                                  Capacity and capability across                                                                                          NHS Lambeth Board         deadline of 26/02/2010 following MT team and Board
                  Deliver an excellent Strategic Plan (SP) underpinned                                                                 SP Steering Group
                  by a resource strategy designed to address the
                                                                                                                                                                                                                             NHS London             Assurance and a period of scrutiny and challenge of      All

                                                                                                       Resources available                                                        A              None identified                 PEC                the strategic objectives. Processes being established  except
                  impact of Health for London and the economic                                                                         Board Monitoring
                                                                                                  Links with Sector and Alliance                                                                                                  MT                to ensure monthly and financial performance monitoring 1 & 10
                  environment in line with NHS London's timetable.
                                                                                                              0x0=0                                                                                                        Key stakeholders         and early alert of risks to the achievement of
                                                                          18-Dec-2009            Changing resource assumptions                                                                                            NHS Lambeth Board
                  To develop our revised Medium Term Financial                                                                         SP Steering Group                                                                                                                                                   Govern
                                                                                                  Capacity and capability across                                                                                             NHS London
                  Strategy to reflect changed economic environment                                                                     WCC Steering Group                                                                                           Key workstreams underway                                ance

                                                                                                             teams                                                                A              None identified                 PEC
                  and to support the Strategic Plan and meet WCC                                                                       Board Monitoring                                                                                             Active engagement of LSL Alliance and SELACU             6
                                                                                                       Links with Sector                                                                                                          MT
                  governance requirements                                                                                                                                                                                                                                                                    11
                                                                                                             3x3=9                                                                                                         Key stakeholders

                  To develop the following key strategies:                                        Capacity and capability across                                                                                          NHS Lambeth Board         Ongoing work to model Polysystems

                  - Polysystems                                                                   teams, NHS London guidance,          Polysystem Steering Group,                                                               MT                  Active engagement with GPs

                                                                                                                                                                                  A              None identified                                                                                               All
                  - Transforming Community Services                                                   Resources available              Management Team                                                                          PEC                 Active engagement with LSL Alliance
                  - Primary Care Strategy                                                                    3x5=15                                                                                                             PBC                 Work programmes not completed by due date

                                                                                                                                                                                                                       PCT NHS Lambeth Board

                                                                                                   Risk of deterioration in PCT's      SP Steering Group
                                                                                                                                                                                                                            Audit Committee                                                                    6

                                                                                                         financial position.           WCC Steering Group
                  To deliver a balanced 2010/11 Operating Plan.
                                                                                                               3x3=9                   Board Monitoring
                                                                                                                                                                                  A              None identified        Performance Committee       Extension of SP and WCC workstreams                        10                 
                                                                                                                                                                                                                             Internal audit                                                                    11
                                                                                                                                                                                                                             NHS London

                  Strategic objective 2
                  To deliver the Operating Plan for 2009/2010 in line with agreed financial and service parameters, 2009/2010 commissioning intentions, national and locally agreed targets (including Local Area Agreement targets).
                                                                          Mar-2009 Mar-2010

                                                                                                  Risk of deterioration in financial                                                                                                                Monthly budget monitoring and reporting framework.         6
                  To deliver 2009/10 the agreed Operating Plan                                                                                                                                                                                                                                                                    

                                                                                                     position /capacity issues.        Management Team                            A              None identified          Management Team           Mitigation plans developed to address under and            10
                  including our commissioning objectives
                                                                                                               4x3=12                                                                                                                               overspending scenarios                                     11

                                                                                                  Resources available and lead in      Commissioning Performance Group                                                  Performance Committee                                                                  All
 MT &

                                                                                                                                                                                                                                                    Develop and begin to implement clear action plans for
                  Deliver key targets / vital signs for 2009/10                                    times for identified red areas      Performance Framework                      A              None identified         NHS Lambeth Board                                                                   except
                                                                                                                                                                                                                                                    red areas and NHS London priorities
                                                                                                               4x3=12                  Performance Committee                                                                 NHS London                                                                      1 & 10

                                                                                                                                   Financial position reported to the NHS                                                NHS Lambeth Board

                  Ensure the delivery of the PCTs statutory financial                           Failure to achieve planned Revenue
                                                                                                                                   Lambeth Board and Audit Committee.                                                  McKinsey's external review   Monthly budget monitoring and reporting framework.         6
                  targets and the PCTs planned financial control total,                          surplus agreed with NHS London.

                                                                                                                                   Budgetary and reporting framework.             A              None identified            Audit Committee         Mitigation plans developed to address under and            10
                  agreed with NHS London, in line with the 2009/10                                         Reputation risk.
                                                                                                                                   Contingency action plan in place to                                                  Performance Committee       overspending scenarios                                     11
                  Operating plan.                                                                               2x3=6
                                                                                                                                   address Acute over spends                                                                 Internal audit
                                                                                                                                                                                                                             NHS London

                                                                                                                                                                                                                         NHS Lambeth board                                                                     1

                                                                                                Failure to achieve planned Revenue                                                                                                                  Delivery of action plan through lead officers
                                                                                                                                                                                                                            Audit Committee                                                                    6
                  Coordinate Use of Resources assessment to deliver                              surplus agreed with NHS London. Process monitored by Audit Committee                                                                               Report and action plan approved by Audit Committee

                                                                                                                                                                                  A              None identified        Performance Committee                                                                  9
                  improvements in Use of Resources assessment                                              Reputation risk.        Use of resource action plan in place                                                                             Oct 09.
                                                                                                                                                                                                                             External Audit                                                                    10
                                                                                                               4x3=12                                                                                                                               Available on request
                                                                                                                                                                                                                             NHS London                                                                        11

                                                                                                                                                                                                                          IM&T Steering Group
                                                                                                        Low uptake of RiO                                                                                                                                                                                        4
                  Ensure the successful implementation of the upgrade                                                                  RiO Project Board                                                                    RiO Project Board

                                                                                                        Delays to version 5                                                       A              None identified                                   RiO 5 successfully went live February 2010                    5
                  to RiO version 5 to time and budget                                                                                  Routine reports from RiO                                                       Directorate Business Meeting
                                                                                                              3x1=3                                                                                                                                                                                              8
                                                                                                                                                                                                                      PCT Performance Committee

                                                                                                                                                                                                                                                                                           1-Rare 2-Unlikely 3-Moderate
                                                                                                                                                                                                                                                                                              4-Almost Certain 5-Certain

                   Controls                                                                                                                                            Consequences                                                                                                                         RAG RATING
                   A-Adequate                                                                                                                               1-Insignificant 2-Minor 3-Moderate                                                                                                               1-6 = Green
                   I-Insufficient                                                                                                                                 4-Major 5-Catastrophic                                                                                                                    8-12 = Amber
                   U-Unclear                                                                                                                                                1 of 5                                                                                                                           15-25 = Red
                                                                         31-Mar-2010 Delivered by (date)

                                                                                                                                                                                                                                                                                                                                  WCC competency
Lead Director

                                                                                                                                                                                             Control A/I/U
                                   Strategic objective                                                             Description of risk                                                                                                       ASSURANCE                                                                                              Code
                                                                                                                                                   What controls have you put in place
                                                                                                                       Risk rating                                                                              Gaps In Control          Sources of Assurance                                 Action                                                Amber
                                                                                                                                                   to ensure delivery of this objective?
                                  Steps to achievement                                                               Consequence                                                                                                               (indicate                                                                                            Green
                                                                                                                      x Likelihood                                                                                                            +ve or -ve)                                                                                          & status

                                                                                                                                                                                                                                         NHS Lambeth Equality
                                                                                                              Not completing actions agreed       Agreements with leads in HR, Strategy &                    No lead in Strategy &                                                                                                3

                To deliver our Equalities action plan
                                                                                                                         3x3=9                    Services and LCH
                                                                                                                                                                                                             Services at present
                                                                                                                                                                                                                                        Performance Committee
                                                                                                                                                                                                                                                                      Most agreed actions underway
                                                                                                                                                                                                                                                                                                                                  5                  

                Objective 3
                To further develop our framework for organisational development, working with McKinsey to review and deliver our organisational development priorities, ensuring a step change in commissioning capability and the identification of
                opportunities to improve productivity and efficiency.
                To develop longer term Organisational Development                                          Failure to achieve objectives due to
                                                                                                                                                  Resources identified to support the
                needs focusing on three key areas: Board                                                     capacity and capability across                                                                                               NHS Lambeth Board

                                                                                                                                                   development of the Strategic Plan.                                                                                 OD Plan in place and performance managed via                All
                development, prioritisation through our Strategic Plan                                                    teams.                                                                                                                MT                                                                                                   

                                                                                                                                                  Planned process of engagement to            A              None identified                                          performance committee                                     except
                process and delivery of increased value for money                                          Failure to engage with partners and                                                                                                  PEC
                                                                                                                                                support the development of the Strategic                                                                              OD plan 2010/2011 agreed                                  5,7&9
                through a step change in productivity and efficiency                                                       staff.
                across all commissioned services.                                                                         3x3=9
                Strategic objective 4
                To deliver our aspirations on the development of competencies and ensure improvement in our World Class Commissioning assessment.

                                                                                                                                                           Performance Management                                                                                     Weekly WCC/SP meeting established and work
                                                                                                           Ability to recruit and retain a suitable        arrangements established.                                                                                  programme underway
                                                                                                            workforce (interim and permanent)        Interims appointed where needed and                                                                              Timescales revised in light of formal SHA extension to
                To deliver all WCC competencies and Governance
                                                                                                            Capacity and resources to deliver           permanent recruitment planned.                                                    NHS Lambeth Board           WCC deadline (now 25th January 2010) with draft

                aspirations agreed by the Board and ensure year on
                                                                                                               the level and pace of change           OD plan in place to support delivery                   Sector/PCT                         MT                    SP/financial plan to be submitted for SHA comments on

                year improvement in our World Class Commissioning                                                                                                                             A                                                                                                                                   All
                                                                                                                           required.                Working with NHS London and the SE                       responsibilities                   PEC                   18th December 2009.
                Assessment and delivery of health outcomes through
                                                                                                               Lack of clarity in Sector/PCT        London Sector to learn from others and                                                  NHS London                Board Seminar 18 January 2010 sign off self
                the delivery of the OD plan.
                                                                                                                       responsibilities.               share learning and good practice.                                                                              assessment and focus on OD needs
                                                                                                                            3x3=9                       Weekly meeting of WCC/SP - all                                                                                Chairs action to sign off outstanding documents
                                                                                                                                                            Directors in attendance.                                                                                  Preparation of WCC panel January to April 2010

                                                                                                             Perception of quality, format and                                                                                         Clinical Leadership Steering
                                                                                                           frequency of information provided to   XIOM system to be launched in                                                                    group

                To ensure Clinical Engagement and effective                                                  PBC; stakeholder survey on PCT       November 2009, selection of                                BSU recruitment,                       PEC

                                                                                                                                                                                              A                                                                       Action plan being overseen by Lucy Day.                       4
                Leadership                                                                                     ability to proactively engage      respondents to survey, PBC business                        stakeholder responses.    PBC Clinical and Corporate
                                                                                                                          clinicians              plans agreed within 8 weeks.                                                              Governance group
                                                                                                                            2x4=8                                                                                                          NHS Lambeth Board

                                                                                                                                                                                                             No Knowledge
                To deliver effective knowledge management enabling
                                                                                                                                                                                                             Management                                               Cross directorate ownership

                generation capture, sharing of information and know                                        Organisation does not have capacity Steering group reporting to Board
                                                                                                                                                                                                             framework/strategy in
                                                                                                                                                                                                                                                                      Investment in additional resource to design strategy.

                how and integrate these into business practices and                                                     to deliver             External consult support with developing          I                                      Knowledge Management                                                                    except
                                                                                                                                                                                                             place                                                    Develop and implement systematised processes and
                decision making to meet WCC competency                                                                    3x3=9                strategy                                                                                    Steering Group                                                                       5,7&9
                                                                                                                                                                                                             Non recurrent posts                                      KM infrastructure
                                                                                                                                                                                                             ending March 2010
                                                                                                             Failure to ensure engagement of
                                                                                                            internal and external stakeholders.   Clear communications and Engagement
                                                                                                           Evidence not used consistency as a     strategy and action plan developed.
                                                                                                           source of evidence in commissioning    Newly established Communications and
                Complete the review of current practice, develop a                                                                                                                                                                      WCC Assurance process
                                                                                                                         decisions.               Engagement Steering Group established

                Communications and Stakeholder Engagement and                                                                                                                                                Initial timetable has       NHS Lambeth Board
                                                                                                               Failure to comply with duty to     with involvement of all Directorates.                                                                               Strategy and action plan signed off and implementation

                supporting action plan to embed a systematic                                                                                                                                  A              slipped due to capacity            MT                                                                                  3
                                                                                                            consult/view of patients and public   Staffing structure recruited to.                                                                                    of new structure underway.
                approach to patient experience and PPI across the                                                                                                                                            issues                            PEC
                                                                                                            not included in the development of    Development of a reporting framework to
                organisation.                                                                                                                                                                                                               NHS London
                                                                                                                           services               ensure that feedback is collated in an
                                                                                                            Capacity and capacity to undertake    accessible and useable format for use
                                                                                                                          this work.              by commissioners

                                                                                                                                                                                                                                                                                                              1-Rare 2-Unlikely 3-Moderate
                                                                                                                                                                                                                                                                                                                 4-Almost Certain 5-Certain

                 Controls                                                                                                                                                         Consequences                                                                                                                                 RAG RATING
                 A-Adequate                                                                                                                                            1-Insignificant 2-Minor 3-Moderate                                                                                                                       1-6 = Green
                 I-Insufficient                                                                                                                                              4-Major 5-Catastrophic                                                                                                                            8-12 = Amber
                 U-Unclear                                                                                                                                                             2 of 5                                                                                                                                   15-25 = Red
                                                                              Delivered by (date)

                                                                                                                                                                                                                                                                                                                              WCC competency
Lead Director

                                                                                                                                                                                       Control A/I/U
                                       Strategic objective                                                 Description of risk                                                                                                          ASSURANCE                                                                                               Code
                                                                                                                                            What controls have you put in place
                                                                                                                Risk rating                                                                               Gaps In Control          Sources of Assurance                                   Action                                                Amber
                                                                                                                                            to ensure delivery of this objective?
                                      Steps to achievement                                                    Consequence                                                                                                                (indicate                                                                                              Green
                                                                                                               x Likelihood                                                                                                             +ve or -ve)                                                                                            & status

                    Strategic objective 5
                    To complete the implementation of Shaping the Future change process incorporating the development of new LSL Alliance and Lambeth Community Health and to identify a preferred option for the future organisational form for Lambeth
                    Community Health (LCH) for approval by the NHS Lambeth Board in line with the Department of Health deadline
                                                                                                        Organisation does not have                                                                                                                                                                                            1

                    Complete implementation of "Shaping the Future"                                                                            Consultation process established                                                   Staff Partnership Forum
                                                                                                    sufficient capacity and capability to                                                                                                                                                                                     4

                    reorganisation ensuring minimal disruption to staff and                                                                        MT weekly monitoring                 A              None identified           Joint Workforce Committee       Complete
                                                                                                                   deliver                                                                                                                                                                                                    8
                    services.                                                                                                                  Communications plan established                                                              PEC
                                                                                                                   0x0=0                                                                                                                                                                                                      11
                                                                                                                                                                                                                                    NHS Lambeth Board
                    To ensure collective commissioning processes with                                                                                                                                                                        MT

                                                                              Mar-2010 Mar-2010
                                                                                                     Ineffective processes resulting in     Governance Arrangements established
                    LSL Alliance and SELACU are developed                                                                                                                                                                           NHS Lambeth Board

                                                                                                    failure to deliver agreed objectives                and agreed.                     A              None identified                                           Regular JCPCT meetings and reporting to PCT Boards           All
                    appropriately and address the needs of Lambeth                                                                                                                                                                      NHS London
                                                                                                                    3x3=9                   Performance reporting systems agreed
                    residents                                                                                                                                                                                                             JCPCTs
                    Ensure the smooth transition of the APO supported by
                                                                                                         Changing Guidance                         Provider APO project                                                                                                                                                       All

                    strong commissioning arrangements including the
                    development of Community Services element of the
                                                                                                    Capacity and resources available         Commissioner APO work (shared with         A              None identified                 Board Seminars
                                                                                                                                                                                                                                                                 Commissioner APO project manager recruited, work
                                                                                                                                                                                                                                                                                                                            except               
                                                                                                                3x3=12                                NHS Southwark)                                                                                                                                                         1&10

                    Strategic objective 6
                    To further develop partnership working through continuing to establish effective mechanisms and structures with London Hub, SELACU, Academic Health Sciences Centre, Local Authority, voluntary sector and other partners to ensure that
                    we commission seamless, joined up and responsive services across health and social care, with a clear customer focus. In doing so to continue to develop excellent relationships with both other commissioners and service providers.

                                                                                                                                                                                                                                         NTA and DH

                                                                                                                                                SLP Executive Delivery Group
                    Ensure representation and contribution to Safer                                    Organisation fails to deliver                                                                                               Performance Committee         Action plan in place with regard to key LAA targets and

                                                                                                                                                         SMU PAG                        A              None identified                                                                                                          2
                    Lambeth Partnership objectives                                                               3x2=6                                                                                                                      Board                associated vital signs
                                                                                                                                                  Performance Framework
                                                                                                                                                                                                                                          SLP Board
                                                                                                                                                                                                                                                                 Continue to monitor through H&WB Board

                                                                                                                                                                                                                                        Lambeth First            Restructure of Children and Young People's Strategic
                    Ensure agreed Health and Well Being and CYP work                                   Organisation fails to deliver

                                                                                                                                                  H&WB Performance Group                A              None identified               NHS Lambeth Board           Partnership in line with Children's Trust guidance is          2
                    programmes and strategies are on track to deliver                                            3x3=9
                                                                                                                                                                                                                                     Safeguarding Board          expected to explore the establishment of a H&WB sub
                                                                                                                                                                                                       Unwieldy governance
                                                                                                                                                                                                       arrangements with LA.
                                                                                                                                                                                                       Lack of capacity to
                    Support the development of Joint Adult Safeguarding                                                                            AD in Adult Safeguarding                            implement training,
                                                                                                                                                                                                                                Adult Safeguarding Partnership   Discussion with LA re streamlining of governance
                    across the borough with partner agencies                                                                                Joint working with partner agencies esp.                   policies and
                                                                                                                                                                                                                                            Board                arrangements to ensure maximum NHS Lambeth                                      

                    Ensure Adult Safeguarding clauses added to all                                                                                             LA                                      procedures.
                                                                                                           Patient safety at risk                                                                                                  Patient Safety & Clinical     engagement

                    relevant contracts and robust monitoring is in place                                                                       Close working with NHS Lambeth           U              Difficulty in gaining                                                                                                    2
                                                                                                                  4x2=8                                                                                                            Governance Sub Group          Primary Care AS lead recruited to help implement
                    Work closely with General Practitioners to provide                                                                                   contract leads                                assurance re
                                                                                                                                                                                                                                   Quality and Governance        policies, promote best practice, develop audit etc. -
                    adult safeguarding training, promote best practice and                                                                      New post of Primary Care Adult                         secondary care
                                                                                                                                                                                                                                          Committee              awaiting start date.
                    develop audit                                                                                                                Safeguarding Lead established                         contracts hosted
                                                                                                                                                                                                       Possible difficulty in
                                                                                                                                                                                                       engaging GPs
                                                                                                                                                                                                                                                              Lambeth Childrens Safeguarding Action plan supported
ST (currently AD)

                                                                                                                                                 Children's Safeguarding board
                                                                                                                                                                                                                                                              by Corporate Directorates including Human Resources
                                                                                                                                            Joint working with partner agencies esp.

                    To work in partnership with local agencies to ensure                                                                                                                                                                                      and Corporate Affairs (Safer Recruitment)
                                                                                                    Children at risk are not supported
                    Children's safeguarding processes continue to be
                                                                                                                                             Interim management arrangement with
                                                                                                                                                                                        A              None identified
                                                                                                                                                                                                                                Children's Safeguarding Board
                                                                                                                                                                                                                                                              Transfer to S&S directorate NHS Lambeth agreed                    2                
                    robust and effective.                                                                                                                                                                                                                     Consideration being given to establishment of
                                                                                                                                            LCH (Angela Dawe) will transfer to NHS
                                                                                                                                                                                                                                                              Safeguarding Children Committee to strengthen
                                                                                                                                                   Lambeth in December 2009
                                                                                                                                                                                                                                                              governance and quality assurance arrangements

                                                                                                                                                                                                                                                                                                          1-Rare 2-Unlikely 3-Moderate
                                                                                                                                                                                                                                                                                                             4-Almost Certain 5-Certain

                     Controls                                                                                                                                               Consequences                                                                                                                                   RAG RATING
                     A-Adequate                                                                                                                                  1-Insignificant 2-Minor 3-Moderate                                                                                                                         1-6 = Green
                     I-Insufficient                                                                                                                                    4-Major 5-Catastrophic                                                                                                                              8-12 = Amber
                     U-Unclear                                                                                                                                                   3 of 5                                                                                                                                     15-25 = Red
                                                                                                          High level Risk Register 2009/2010                                                                                        Appendix 2
                                                                                                                  as at 03 March 2010
Lead director

                                                                                    Description of risk

                                                                                                                                              Control A/I/U

                                                                  Delivered by
                                                                                                             What controls have you put                                               Expected Sources of Assurance                                                                Red


                                2008/09 Objective                                       Risk rating          in place to ensure delivery                        Gaps In Control                 (indicate                              Actions                                    Amber
                                                                                      Consequence                 of this objective?                                                           +ve or -ve)                                                                        Green
                                                                                       x Likelihood                                                                                                                                                                              & status

                Deliver a balanced 2009/10 Operating Plan
                                                                                  Risk of deterioration in   Budgetary and reporting                                                                                   Monthly budget monitoring and reporting
                financial framework within the PCT Financial                                                                                                                                      CSG

                                                                                 PCT's financial position.   framework.                                                                                                framework.

                Strategy and that supports effective service                                                                                   A                None identified             Audit Committee                                                        11
                                                                                    4x3=12 Jan 2010          Audit Committee                                                                                           Mitigation plans developed to address
                investment and efficiency proposals and                                                                                                                                    NHS Lambeth Board
                                                                                   3x3=9 March 2010          Cash management strategy                                                                                  under and overspending scenarios.
                addresses financial risk management.
                Provide commissioning input to APO transfer                       Changing Guidance

                including development of Community Services                      Capacity and resources APO project (shared with                                                                                       Interim position for APO contract lead

                                                                                                                                               A                None identified        NHS Lambeth Board Seminars                                                except
                element of SP (previously Transforming                                  available       NHS Southwark)                                                                                                 recruited to
                                                                                                                                                                                                                                                                 1 & 10
                Community Services)                                                     3x3= 12
                                                                                                                                                                                                                       Patient experience paper to be
                                                                                                                                                                                          Patient Safety & Clinical
                                                                                                                                                              Insufficient capacity                                    presented to MT (March 2010)

                Improve use of patient experience data to drive
                                                                                 Improvements in care not
                                                                                                          Patient safety and Clinical                           to analyse data to
                                                                                                                                                                                                                       Patient Experience being strengthened        3              

                                                                                        realised                                                  I                                             sub committee
                forward improvements in health care                                                       Governance sub committee                             identify action plan                                    in contracts                                 5
                                                                                         4x3-12                                                                                       Quality & Governance Committee
                                                                                                                                                                   and priorities                                      Agreement to appoint Director of Public
                                                                                                                                                                                             NHS Lambeth board
                Development of a six monthly Health and
                Safety workplan for both NHSL and LCH                                                        Clear prioritised action plan

                incorporating                                                     Failure to comply with     of key H&S priorities with                                                            Board

                                                                                                                                                                                                                     H&S action plan
                * mandatory training                                              legislation/Health and     leads identified                                                                       MT

                * development of local health and safety plans                    Safety issues for staff    Delivery of the plan in line
                                                                                                                                               A                None identified
                                                                                                                                                                                      Quality & Governance Committee
                                                                                                                                                                                                                     Monitoring of progress ongoing via H&S                        
                                                                                                                                                                                                                     action group
                * review of governance arrangements for both                              4x3=12             with agreed success criteria                                                         H&SAG
                LCH and NHS L

                                                                                                                                                                                                                                                   1-Rare 2-Unlikely 3-Moderate
                                                                                                                                                                                                                                                      4-Almost Certain 5-Certain

                    Controls                                                                                                                  Consequences                                                                                                        RAG RATING
                    A-Adequate                                                                                                     1-Insignificant 2-Minor 3-Moderate                                                                                               1-6 = Green
                    I-Insufficient                                                                                                       4-Major 5-Catastrophic                                                                                                   8-12 = Amber
                    U-Unclear                                                                                                                      4 of 5                                                                                                          15-25 = Red
                                                                               Risk to the health of the population
                                                                                                                      Department of Health guidance.                                                Lessons learnt report to MT
                                                                               from the 'flu pandemic Risk to NHS                                                                                                                                                                                                          1

                                                                                                                      Influenza Pandemic Committee,                                                          26.03.2010
                                                                                 Lambeth reputation if the H1N1                                                                                                                    Lessons learnt process in progress                                                      3
        H1N1 (Swine Flu) Pandemic                                                                                     Pandemic Operational Group & 4                A    None identified             Chair to review by end of
                                                                                   Campaign is ineffective or                                                                                                                      Readiness to be maintained as the situation could rapidly change                        4
                                                                                                                      Workstreams with representation from                                                   March 2010
                                                                                             inaccurate                                                                                                                                                                                                                    5
                                                                                                                      across the local health community                                            Full report to April 2010 Board
                                                                                                                                                                                                                               Action Plan in place
                                                                                                                    Infection Control Committee                                                                                                                                                                            2

                                                                               Risk to the population of infectious                                                                                Regular monthly performance Key objectives
                                                                                                                    Regular Monitoring and surveillance                                                                                                                                                                    3          

        Infection Control                                                                   diseases                                                                A    None identified                    reporting          Surveillance of Community Acquired HCAIs
                                                                                                                    and mandatory training for staff                                                                                                                                                                       4
                                                                                             3x2=6                                                                                                  Quarterly meetings of ICC  Monitoring of compliance with CQC requirements
                                                                                                                    Policy review                                                                                                                                                                                          5
                                                                                                                                                                                                                               Review all GP infection control self audits
        Current Occupational Health arrangements are not                       Inadequate / untimely treatment and

        robust and do not provide out of hours assessment,                       support in relation to blood born Interim arrangements in place for LCH                 Service provision for      Infection Control Committee

        treatment and advice for needlestick injuries,                           viruses. Litigation / complaints / Contract negotiations well underway             U    PC and dental not yet         Workforce Committee        Negotiations with G&ST underway overseen by IC working group                            1c
        incidents involving body fluid, splashes etc for                                adverse publicity.          with GSST                                            finalised                      NHS Lambeth Board
        directly managed staff and independent contractors                                     3x2=6

                                                                                Changes in Polysystem Strategy                                                                                        Strategic Capital Group     West Norwood to Sept 09 Board
        Support preparation of business cases for: Akerman                                                            Individual Project Boards
                                                                                 Business cases not signed off                                                                                         NHS Lambeth Board          Akerman Road to January 10 Board                                                         2

        Road, Future Clapham, Crowndale & West Norwood                                                                LIFT Management Group                         A    None identified
                                                                                         Affordability                                                                                                Scheme Project Boards       Crowndale - being developed                                                              6
        and Brixton                                                                                                   Strategic Capital Group
                                                                                            3x3=9                                                                                                               SPB               Brixton on hold pending Polysystem and LBL review
                                                                                                                                                                                                   Information Governance and
                                                                                Confidentiality of patient and other                                                                                    Caldicott Committee
        Ensure Information Governance Strategy and Policy

                                                                                              records                Review of Information Governance                                                Quality and Governance
        continue to meet current requirements. Action plan to                                                                                                                                                                                                                                                              5

                                                                                        Reputation risks             Strategy and Policy                            A    None identified                    Committee             Action plan in place and available on request
        ensure improvements in information management                                                                                                                                                                                                                                                                     10
                                                                                               3x3=9                 Review of training                                                                    Internal Audit
                                                                                                                                                                                                           NHS London
        Top Patient Safety risks
                                                                               Delays in receiving key performance
                                                                               returns from SLAM, lack of borough                                                        SLAM: quality of                                         Joint MT team meeting with SLAM November 2009, SLAM attendance at


        SLAM: quality of information and learning from SUIs/                       specific reports on SUIs and    Identified as a priority for the Board and            information and                                          Governance committee meeting December, Board to Board meeting in early Feb               8
        Homicides                                                                evidence of learning from SUIs:   MT
                                                                                                                                                                         learning from SUIs/
                                                                                                                                                                                                     Quality and Governance
                                                                                                                                                                                                                                  2010, CQUINs, ongoing contract monitoring. Quality schedule agreed. Update on           10          
                                                                                       patient safety at risk                                                            Homicides                                                progress to MT in March 2010.
                                                                                                                                                                                                                                  Action plan drafted by Prof Ami David presented at PEC November 2009.
                                                                                         Patient Safety                                                                                                        PEC

                                                                                                                      Identified as a priority for the Board and                                                                  LCH actively addressing issues e.g. rebanding 6s to 7s, recruitment premia and

        Lambeth Community Health: review of Health Visiting                       Recruitment and Retention of                                                           LCH: Failing to deliver              CYPS                                                                                                         8
                                                                                                                      MT through risk management and                U                                                             strengthening relationships between HV teams and practices
        Services and delivery of action plan.                                            Health Visitors                                                                 agreed action plans.        Quality and Governance                                                                                               10
                                                                                                                      highlighted by LA                                                                                           LCH has established 4 workstreams - Partnership, Perfomance, Profile and
                                                                                             4x2=8                                                                                                          Committee
                                                                                                                                                                                                                                  Productivity. A delivery plan for each wrokstream will be in place by March 2010
        Equitable Access to Primay Care Programme - GP
                                                                                                                      Incident investigation carried out

        walk-in services                                                       Lambeth residents unable to access                                                                                    Issues of concern panel      SELDOC dealing with internal issues                                                      1
                                                                                                                    Meeting with SELDOC CEO and Dir of

        Concern regarding adequate GP cover arrangements                       GP walk-in services - Patient safety                                                 A        None identified         Quality and Governance       Report to Issues of Concern Panel to be held on 16/02/2010 recommending issue            4
        by SELDOC for the above following an incident of no                                  4x2=8                                                                                                          Committee             of a Remedial notice                                                                     7
        GP cover on 26/12/09
                                                                                 Potentially some newborns not            Incident investigation underway                                              Incident findings and                                                                                               2

        Newborn blood spot screening serious untoward                                                                                                                         Failsafes and                                       Working group to be convened

                                                                                        being screened                      following declaration of SUI            U                                    recommendations                                                                                                   5

        incident                                                                                                                                                               standards                                          Action plan to be drawn up
                                                                                             4x3=12                                                                                                        Future audits                                                                                                  11

                                                                                                                                                                                                                                                                                                      1-Rare 2-Unlikely 3-Moderate
                                                                                                                                                                                                                                                                                                        4-Almost Certain 5-Certain

          Controls                                                                                                                                                     Consequences                                                                                                                                  RAG RATING
          A-Adequate                                                                                                                                        1-Insignificant 2-Minor 3-Moderate                                                                                                                         1-6 = Green
          I-Insufficient                                                                                                                                          4-Major 5-Catastrophic                                                                                                                             8-12 = Amber
          U-Unclear                                                                                                                                                        5 of 5                                                                                                                                     15-25 = Red

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