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					           RCHT Trust Board May 28th
                             2009/10 Board Assurance Framework
                                                                                                                                                                          (1st Iteration)
    Risk Principle Risks by Key  Risk              Residue Lead Director          Key Controls                        Assurances on Controls               Gaps in Controls and Actions                       Gaps in Assurances and Actions
     Ref Areas             What Scoring            Risk                              What controls / systems are in                        Where do we                          Where are we failing to put            Where we are failing to gain
           could prevent this objective               Impact    Accountable for     place to secure delivery of the   gain proof / outcomes our controls   effective controls/systems in place? What action      assurance/proof that the controls are
                 being achieved?          Impact            X   management of                 objective?                         are effective?                               needs taking?                      effective? What action needs taking?
                                              X    Likelihood        risk



    Overarching Objective - MORE TIMELY AND EFFECTIVE CARE

                             Objective 1) To achieve all national and local access targets while delivering contracted activity levels.
     1a Risk of planned                   4x3      4x2          Dir of Health     1. There is a Service               1.1 Minimal short notice             1. The SIP is not yet fully in place; key          1. SIP will monitor itself to ensure
        capacity not aligned               = 12           =          Info         Efficency and Imporvement           (high cost) capacity.                absence of a Project Manager to lead.              adequate assurances are in place
        with Demand.                               10                             Programme set up to deliver         1.2 High utilisation of              Action:                                            and effective.
                                           amber   amber                          an accurate Demand profile.         planned capacity.


                                                                                                                                         1.3
          S4BH - C7f -                                                            2. An effective                     2.1 This model is used               2. Not a full uptake (& understanding)             2. As above
          declaration n/a;                                                        demand/capacity model               operationally and for                from the Divisional Managers and
          assessed by other                                                                                           planning by the Divisions            Service Leads. Action:
          measures

                                                                                                                       2.2 Progress is reported
                                                                                  3. Full understanding of            3.1 By use of the                    3.1 See above (2)                           3. As above
                       C19 -
                                                                                  Demand/Capacity theory              demand/capacity model                3.2 Bring in an external expert / speaker /
        declaration n/a;
                                                                                  within the Divisions                                                     facilitator to bring best practice into the
        assessed by other                                                                                                                                  Trust
        measures
     1b Incomplete delivery of            4x3      4x2          Dir of Health     1. The Health Informatics           1. Through the success of                                                               1. Escalation route yet to be agreed
        the Health Informatics              = 12      =8             Info         Programme Board (Clinical)          the individual projects and                                                             from these Informatics Boards.
        Development                                                               is effective (from February         therefore the programme as                                                              Action: R. Johnson / HIP Board
        Programme                          amber   yellow                         2009) ensuring the right            a whole.
                                                                                  decisions are made on
                                                                                  Informatics developments.
          S4BH - D6 -                                                             2. Ensure adequate capital          2. See above (1)                     2. Increasing concern at indiactions that          1. Escalation route yet to be agreed
          Developmental                                                           and revenue budgets are                                                  the capital budget will be inadequate to           from these Informatics Boards.
          Standard                                                                allocated to the programmes                                              deliver on the programme as set out.               Action: R. Johnson / HIP Board
                                                                                                                                                           This is being pursued through Capital
                                                                                                                                                           Management Board. Action: R. Johnson:
                                                                                                                                                           29th May

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




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    Risk Principle Risks by Key  Risk              Residue Lead Director          Key Controls                        Assurances on Controls               Gaps in Controls and Actions                       Gaps in Assurances and Actions
     Ref Areas             What Scoring            Risk                              What controls / systems are in                        Where do we                          Where are we failing to put            Where we are failing to gain
           could prevent this objective               Impact    Accountable for     place to secure delivery of the   gain proof / outcomes our controls   effective controls/systems in place? What action      assurance/proof that the controls are
                 being achieved?          Impact            X   management of                 objective?                         are effective?                               needs taking?                      effective? What action needs taking?
                                              X    Likelihood        risk

           S4BH - D6 -
           Developmental
           Standard
     1d National Programme to 4x5                  4x4             Acting         1. EMSA Programme Board - 1.1 Minutes of EMSA                            1.1 Consideration beyond current                   1.1 Proposed programme needs to
        Eliminate Mixed-Sex         =               = 16         Director of      developed programme of    Programme Board.                               programme is needed as total EMSA is               be signed off by the Divisional
        Accommodation         20                                  Nursing,        work, overseeing and        1.2 Minutes of Working                       not achieveable by end June '09                    Management Teams & EMT
        (EMSA) by June '09        red               amber        Midwifery &      monitoring progress       Group 1.3 Fortnightly
                                                                    AHPs                                    progress reports to EMT &                      1.2 Management solutions to achieve
                                                                                                            PCT/SHA                                        single sex accommodation are required
                                                                                                                                                           through consideration of specialty vs
                                                                                                                                                           gender nursing
           S4BH - C20b - non-
           compliant 08/09
     1e Lack of theatre                     tbc      tbc        Dir of Service 1. Revised theatre max                 1.1 Minutes of theatre max.          1. Lack of good information & dedicated            1. Lack of information as described
        capacity for key                                           Delivery    group in place to monitor                                                   information analysts hampers                       makes assurance difficult. Additional
        specialties e.g. gynae,                                                theatre use & address                                                       understanding of the problem. Urgent               informatics resources for 09/10 need
        orthopaedics.                                                          inefficiencies.                                                             need for additional analytical support.            to be agreed by exec team and then
                                                                                                                                                           Action:                                            implemented. Action:


                                                                                                                                            1.2
                                                                                                                      Monthly Divisional
           S4BH - C7f -                                                           2. Major arm of Service             2.1 Monitoring of progress
           declaration n/a;                                                       Improvement Programme is            via SIP Board.
           assessed by other                                                      to address efficiencies of
           measures)                                                              theatres.
                                                                                  3. Business plan for T and A        3. As above in 1.2       2.2 As
                                                                                  includes additional allocation
                                                                                  for increased staffing levels
                                                                                  for 09/10
      1f   Failure to agree                 tbc      tbc        Dir of Service 1. Revised Getting Patients            1. Via GPT meeting once              1. GPT not yet established.                        1. As noted, systems and processes
           appropriate care                                     Delivery /     Treated group will address             established                                                                             in the community remain in their
           pathways with PCT eg.                                               cross cutting themes with                                                                                                      infancy.
           Oral surgery and                                                    PCT. Also will be reviewed
           ophthalmology in order                                              as part of Divisional                                  1.2
           to contain demand                                                   performance reviews.                   Monthly performance
                                                                                                                      reviews with PCT and SHA
           S4BH - C6 -                                                                                                seek adequate assurances.
           compliant 08/09

     1g Poor management of                  tbc      tbc        Dir of Service 1. Weekly performance                  1. Through weekly                    1. Real time bed system not yet in place. 1. Further work required with PCT
        patient flow leading to                                    Delivery    dashboard gives early signal           performance reports and              Action: R.Johnson / Clinical Site Manager through GPT mechanism to ensure
        lack of surgical beds at                                               of problems. Daily bed                 monthly reports to Board.                                                      strategy for unscheduled care agreed.
        the appropriate time                                                   meetings and daily                     Through progress and
                                                                               dashboard alert to daily               performance management
                                                                               problems. Patient flow                 of Service improvement
                                                                               project forms part of Service          programme.
                                                                               improvement programme




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                                            tbc      tbc



    Risk Principle Risks by Key  Risk              Residue Lead Director          Key Controls                        Assurances on Controls               Gaps in Controls and Actions                       Gaps in Assurances and Actions
     Ref Areas             What Scoring            Risk                              What controls / systems are in                        Where do we                          Where are we failing to put            Where we are failing to gain
           could prevent this objective               Impact    Accountable for     place to secure delivery of the   gain proof / outcomes our controls   effective controls/systems in place? What action      assurance/proof that the controls are
                 being achieved?          Impact            X   management of                 objective?                         are effective?                               needs taking?                      effective? What action needs taking?
                                              X    Likelihood        risk

          S4BH - C7f -
          declaration n/a;
          assessed by other
          measures




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    Risk Principle Risks by Key  Risk              Residue Lead Director          Key Controls                        Assurances on Controls               Gaps in Controls and Actions                       Gaps in Assurances and Actions
     Ref Areas             What Scoring            Risk                              What controls / systems are in                        Where do we                          Where are we failing to put            Where we are failing to gain
           could prevent this objective               Impact    Accountable for     place to secure delivery of the   gain proof / outcomes our controls   effective controls/systems in place? What action      assurance/proof that the controls are
                 being achieved?          Impact            X   management of                 objective?                         are effective?                               needs taking?                      effective? What action needs taking?
                                              X    Likelihood        risk


                 Objective 2) To implement the Service Efficiency and Improvement Programme - working with the PCT to redesign
                            patient pathways to improve patient experience, clinical outcomes and the use of resources.
     2a Failure to identify &   5x4     5x2                     Dir of Finance 1. Service improvement       1.1 Minutes & agendas of                       1.1 Project management arrangements                1.1 Detailed plans for all of the 13
        implement a robust set     = 20 = 10                                   board established to oversee Service Improvement                            for projects yet to be finalised as at 12          projects have yet to be completed.
        of service                                                             and ensure delivery          Board.                                         May 2009. The Service Improvement                  There is presently inadequate
        improvements for the        red amber                                  alongside resourced Service                                                 Board need to urgently ensure project              assurance to the Board that the plans
        Trust both in the                                                      Improvement Team.                                                           management arrangements are robust                 in place are sufficient to meet the
        current year and future                                                                               1.2 Project Management                       for all projects. Action: J.Teape/SIP              requirement to realise efficiency
        years resulting in                                                                                  Plan for overall project.                      Board: end May 09                                  gains of £12.5m in 09-10. Urgent
        potential WEAK use of                                                                                                                                                                                 action is ongoing through May to
        resources assessment,                                                                                                                                                                                 establish detailed & robust plans with
        failure to maximise                                                                                                                  1.3.                                                             milestones. Action: Action:
        value for money within                                                                                        Project Initiation Documents                                                            J.Teape/SIP Board: end May 09
        the Cornish Health                                                                                            for the individual projects.
        Economy, & loss of
        confidence in Trust
        Board from key
        external stakeholders.


          S4BH: D5b                                                               2. Finance reports to Board         2.1. Routine risk assessed           2.1 As above                                       2.1 As above
          (not assessed as part                                                   and Finance Committee               reports to Board and
          of 08-09 declaration)                                                   outlining progress on the           Finance Committee
                                                                                  delivery of the Service             outlining progress against
                                                                                  Improvement Programme               annual plan.
                                                                                                                            2.2. Internal Audit
                                                                                                                      annual review of Service
                                                                                                                      Improvement plan
                                                                                                                      scheduled for 2009-10.
                                                                                  3. Medium Term Financial            3. Medium Term Financial             3.1 An efficiency stragey approved 08-09           3 Until a fully integrated medium term
                                                                                  Strategy and Recovery plan          Strategy                             but a revised recovery plan & Trustwide            strategy is in place underpinned by
                                                                                  sets out how the required                                                approach to the medium term needs to               financial, estates, service, capacity
                                                                                  level of efficiency will be                                              be established, documented & reported              and workforce plans, and a medium
                                                                                  achieved beyond the current                                              to Board. Approach accepted in principle           term recovery plan, the Board do not
                                                                                  financial year.                                                          March 2009. Needs finalising in a formal           have assurance actions are in place
                                                                                                                                                           strategy. Action: J.Teape: Q1                      to ensure long term financial stability.
                                                                                                                                                                                                              Action to develop integrated plans to
                                                                                                                                                                                                              be prioritised in early 09-10. Action:
                                                                                                                                                                             3.2 Full integration with        J.Teape/D.Hastings/J.Perry:Q1
                                                                                                                                                           the MTFS of Estates, Workforce and
                                                                                                                                                           Capacity strategies presently not in
                                                                                                                                                           place. These documents should all be
                                                                                                                                                           consistent & is an urgent requirement
                                                                                                                                                           early 09-10. Action:
                                                                                                                                                           J.Teape/D.Hastings/J.Perry:Q1




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    Risk Principle Risks by Key  Risk              Residue Lead Director          Key Controls                        Assurances on Controls               Gaps in Controls and Actions                       Gaps in Assurances and Actions
     Ref Areas             What Scoring            Risk                              What controls / systems are in                        Where do we                          Where are we failing to put            Where we are failing to gain
           could prevent this objective               Impact    Accountable for     place to secure delivery of the   gain proof / outcomes our controls   effective controls/systems in place? What action      assurance/proof that the controls are
                 being achieved?          Impact            X   management of                 objective?                         are effective?                               needs taking?                      effective? What action needs taking?
                                              X    Likelihood        risk

                                                                                  4. Monthly Divisional               4. Monthly Divisional                4. Reports need redesigning for 09/10.             4. The majority of plans for Divisions
                                                                                  performance reviews take            Reports                              Action in hand to redesign reports.                and Directors efficiency have been
                                                                                  place to review Divisional                                               Action: J.Teape/A. Murphy Q1                       received and are robust but not all
                                                                                  performance against                                                                                                         plans are yet in place and until the
                                                                                  efficiency targets.                                                                                                         year commences and delivery is
                                                                                                                                                                                                              evidenced, full assurance cannot be
                                                                                                                                                                                                              confirmed. Remaining action is to
                                                                                                                                                                                                              finalise plans & evidence delivery.
                                                                                                                                                                                                              Action: J.Teape/A. Murphy Q1


     2b Failure to provide a              4x4    4x2              Acting          1. Risk currently managed by 1. Anaesthesia & Theatres                   1. Business Case Required. Action:                 1. Report adverse clinical events as
          centralised facility for          = 16       =        Medical Dir       Critical Care Outreach.      Management Team.                                                                               part of Performance Review up to
          patients who fulfill                   8              (Operations)                                                                                                                                  Board Level. Action: J. Paddle: 30th
          the need for Level 2              red                                                                                                                                                               June 09.
          care (High                              yellow
          Dependancy Unit)
          S4BH - C5a- Non
          Compliant 08/09
     2c Pressure on Acute                 4x5      4x3            Acting          1. Division Monitors Medical        1. Division of Acute                 1. Gaps in control are currently being             1. No Routine monitoring of possible
        Medical Beds leading              = 20        = 12      Medical Dir       Outliers and use of stroke          Medicine management                  identified as part of transition of medical        adverse effect on mortality. Reporting
        to poor patient                                         (Operations)      ward.                               team.                                leadership Action: R.Sinclair                      of Hopital Standardised Mortality
        experience.                         red                                                                                                                                                               Rate (HMSR) for Division of Acute
                                                   amber                                                                                                                                                      Medicine as part of performance
                                                                                                                                                                                                              review up to Board Level. Action:
                                                                                                                                                                                                              R.Sinclair: 30th June 09

          S4BH - C13a - Non
          Compliant 08/09
          C19 - declaration n/a;
          assessed by other
          measures

     2d Failure to optimise               4x4      4x2            Acting          1. Massive agenda of                1. Divisional Management             1. Gaps in control are currently being             1. Monthly Reports from Theatre
          theatre capacity                 = 16          =8     Medical Dir       change in practice currently        Team, Anaesthesia &                  identified as part of transition of medical        Management Board to Exec team
          inclusive of waiting                                  (Operations)      ongoing                             Theares.                             leadership Action: R.Sinclair                      and Board. Action: D.Byrne: 31st
          list utlisation                    red   yellow                                                             1.1 Theatre Management                                                                  May 09
                                                                                                                      Board
          S4BH - C7f -
          declaration n/a;
          assessed by other
          measures




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    Risk Principle Risks by Key  Risk              Residue Lead Director          Key Controls                        Assurances on Controls               Gaps in Controls and Actions                       Gaps in Assurances and Actions
     Ref Areas             What Scoring            Risk                              What controls / systems are in                        Where do we                          Where are we failing to put            Where we are failing to gain
           could prevent this objective               Impact    Accountable for     place to secure delivery of the   gain proof / outcomes our controls   effective controls/systems in place? What action      assurance/proof that the controls are
                 being achieved?          Impact            X   management of                 objective?                         are effective?                               needs taking?                      effective? What action needs taking?
                                              X    Likelihood        risk

     2e Inappropraite case                5x2      5x1            Acting          1. MEWS Triage in WCH               1. West Cornwall Hospital            1. Implementation of an Evidence-based             1.1 No satandardised report in place.
           selection for acute                      =5          Medical Dir       Casualty                            Project Group                        risk assessment tool for Acute                     MEWS Triage data from WCH
           admissions at West             = 10                  (Operations)                                                                               Admissions to West Cornwall Hospital.              Casualty must be reported to WCH
           Cornwall Hospital                                                                                                                               PEC (May 5th) & DCGC Apr / May need                Project Board. Ray Sinclair 31st April
           leading to risk of              amber   yellow                                                                                                  proforma. SWAST Governance Com.                    2009
                                                                                                                                                           Action: R. Sincalir: 31st June 09.
           delay in specialist
           treatment.

           S4BH - C5a - Non
           compliant 08/09

      2f   Lack of clinical buy into        tbc      tbc           Acting      1. Regular review via                  1. Minutes of Divisional   1. GPT process needs to be formally                          1. Improved reporting on progress
           Service Improvement                                    Medical      Divisional Directors Board             Directors' Board and       established to agree programme of work,                      required through service
           Programme can bring                                    Director     and GPT meeting.                       Service improvement Board. outcomes, timescales and                                     improvement Board, and through SIP
           slow pace of change in                               (Operations) /                                                                   resopnsibilities. Clinical leads for each                    Board to the Trust Board.
           delivering new                                           CEO                                                                          major programme in sIP now required.
           pathways that limits                                                                                                                  Cascade of information and rebranding
           delivery of 09/10                                                                                                                     in organisation also required.
           progress and savings.

           S4BH - C7d -                                                           2.. Service Improvement             2.. Minutes of SIP        As above                                                      2.. Clear programme of work for GPT
           declaration n/a;                                                       Board, Finance Committee,           programme board and Trust                                                               with timescales and responsibilities
           assessed by other                                                      Trust Board.                        Board. GPT not yet                                                                      now needs to be established with
           measures                                                                                                   established.                                                                            proper reporting and performance
                                                                                                                                                                                                              management responsibilities. Action:
                                                                                                                                                                                                              R. Sinclair
    2g     Organisational learning          tbc      tbc           Acting         1. Discharge/transfer               1.1 TOR for new group                1.1 New group - first meeting arranged             1.1 New group - first meeting
           from compromised                                      Director of      outcome review group -                  1.2 Minutes from review          but not yet convened.                              arranged but not yet convened.
           patient discharge /                                    Nursing,        alternate month review by           group 1.3 Action plans -
           transfer outcomes                                     Midwifery &      joint acute, community and          reviews and sign off on
                                                                    AHPs          social care. Include pathway,       completion (action plans
                                                                                  processes, documentation.,          from review group & RCAs)
                                                                                  monitoring of all action plans.


           S4BH - C13a - Non                                                      2. Significant event meetings       2.1 RCAs from significant            2.1 New initiative                                 2.1 New initiative
           compliant 08/09                                                        - ad hoc in response to             event meetings with
                                                                                  individual cases.                   ensuing action plan


    2h     Proactive and Effective          tbc      tbc           Acting         1. PPI Steering Group               1.1 Minutes from the                                                                    1.1 The organisation cannot currently
           Patient and Public                                    Director of                                          Steering Group.                                                                         demonstrate inclusion of patients
           Involvement (PPI) in all                               Nursing,                                                           1.2 Minutes                                                              and/or the public in local
           efficiency and                                        Midwifery &                                          from the Supporting Care                                                                development or strategic plans - to
           improvement                                              AHPs                                              Governance Committee                                                                    be discussed by EMT & strategy for
           programmes (both                                                                                                                                                                                   inclusion developed.
           ongoing planning of
           services and major
           changes)




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                                            tbc      tbc          Acting
                                                                Director of
                                                                 Nursing,
                                                                Midwifery &
                                                                   AHPs
    Risk Principle Risks by Key  Risk              Residue Lead Director          Key Controls                        Assurances on Controls               Gaps in Controls and Actions                       Gaps in Assurances and Actions
     Ref Areas             What Scoring            Risk                              What controls / systems are in                        Where do we                          Where are we failing to put            Where we are failing to gain
           could prevent this objective               Impact    Accountable for     place to secure delivery of the   gain proof / outcomes our controls   effective controls/systems in place? What action      assurance/proof that the controls are
                 being achieved?          Impact            X   management of                 objective?                         are effective?                               needs taking?                      effective? What action needs taking?
                                              X    Likelihood        risk

          S4BH - C17 - Non-                                                       2. PPI elements to Outline                                               2.1 Consultation cannot currently be
          compliant 08/09                                                         and Full Business Cases                                                  demonstarted through the Business case
                                                                                                                                                           development process - this needs to be
                                                                                                                                                           reinforced by the Business case review
                                                                                                                                                           Group
                                                                                  3. Identified Independent           3.1 Action plan for work
                                                                                  Patient Ambassadors allied          undertaken by the
                                                                                  to the Trust                        Ambassadors




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    Risk Principle Risks by Key  Risk               Residue Lead Director          Key Controls                        Assurances on Controls               Gaps in Controls and Actions                       Gaps in Assurances and Actions
     Ref Areas             What Scoring             Risk                              What controls / systems are in                        Where do we                          Where are we failing to put            Where we are failing to gain
           could prevent this objective                Impact    Accountable for     place to secure delivery of the   gain proof / outcomes our controls   effective controls/systems in place? What action      assurance/proof that the controls are
                 being achieved?          Impact             X   management of                 objective?                         are effective?                               needs taking?                      effective? What action needs taking?
                                              X     Likelihood        risk



    Overarching Objective - SAFER CARE

               Objective 3) To reduce the rates of MRSA and other healthcare associated infections through the application of best
                                               practice to provide a clean and healthy environment.
     3a Failure to meet                   4x2       4x2          Director of       1. Trust Cleaning                   1.‘Ward to Board Reporting’          1. Trust Cleaning Specifcation &                   1. Formalisation of existing dialogue
        national cleaning                                        Estates and       Specification & protocols in        in place. Cleanliness audits         Protocols to be repackaged into a                  between Infection Control Team &
        specifications for                =8        =8             Facilites       place to monitor the                are reported to Wards,               Cleaning Policy for clarity of                     Hotel Services Team. Action:
        cleanliness                                                                achievement of cleaning             HICC, Nursing Board &                responsibility. Action: M.Pearson / Q1             M.Pearson / Q1
                                           yellow   yellow                         standards across the Trust          Trust Board.                                                                                        1.2 Further enforcement
                                                                                                                                                                                                               of Ward Managers as responsible for
                                                                                                                                                                                                               outcome of cleanliness standards on
                                                                                                                                                                                                               their ward. Action: C.Rashleigh / Q1

          S4BH - C4a -
          Compliant


     3b Failure to manage      3x3    3x2                        Director of       1. Waste Management Policy          1. Ward level risk                   1. The Policy must be strictly enforced            1. Auditing of segregation/sorting of
        waste effectively,         =9   =6                       Estates and       in place which governs the          assessments, weekly                  across the Trust to ensure waste is                waste and reviews of ward level risk
        maximise recycling and                                     Facilites       segregation, storage,               exception reporting of waste         treated appropriately at ward level prior          assessments/practice are included in
        minimise quantity of                                                       handling, transport and             service failures to director.        to collection at site disposal points.             the 09/10 waste Action Plan.
        waste created           amber yellow                                       disposal of waste.                  Handling, transportation and         Action: C.Rashleigh                                Action:S.Butler
                                                                                                                       disposal documents.

          S4BH - C4e -                                                             2. The Trust has in place           2. Contracts are monitored
          Compliant 08/09                                                          Contracts with experienced          by relevant leads with
                                                                                   waste contractors for the           reporting channels in place
                                                                                   removal/disposal of waste           to director.
                                                                                   from trust sites.
     3c Failure to effectively            3x3       4x2          Director of       1. Planned Preventative             1. PPM records, Risk                 1. PPM, Risk Assessed Backlog & all                1. The majority of existing assurance
        manage or maintain                  =9        =8         Estates and       Maintence (PPM) &                   Assessed Backlog records,            infrastruture maintenance/management               records to date are all wthin a paper
        building assets /                                          Facilites       Inspection Programme, Risk          external inspection records          protocols to be repackaged into a Estate           based system which is not easy to
        equipment leading to                amber                                  Assessed Backlog                                                         Management Policy for clarity of                   interrogate; this system is being
        service failure                             yellow                         Programme, external                                                      responsibility. Action: D.Hastings / Q1            replaced with an information system
                                                                                   inspection of regulated                                                                                                     which will allow more effective
                                                                                   equipment.                                                                                                                  interrogation of maintenace
                                                                                                                                                                                                               performance improving assurance
                                                                                                                                                                                                               reporting. Action: D.Hastings

          S4BH - C21 -
          Compliant




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    Risk Principle Risks by Key  Risk              Residue Lead Director          Key Controls                        Assurances on Controls               Gaps in Controls and Actions                       Gaps in Assurances and Actions
     Ref Areas             What Scoring            Risk                              What controls / systems are in                        Where do we                          Where are we failing to put            Where we are failing to gain
           could prevent this objective               Impact    Accountable for     place to secure delivery of the   gain proof / outcomes our controls   effective controls/systems in place? What action      assurance/proof that the controls are
                 being achieved?          Impact            X   management of                 objective?                         are effective?                               needs taking?                      effective? What action needs taking?
                                              X    Likelihood        risk

     3d Failure to provide a              5x3      4x2           Director of      1. Health and Safety, Fire          1. Internal inspection &             1. Improvements in auditting of                    Assurance reporting from Ward to
        safe and secure                    = 15    =8            Estates and      and Security Policies in place      auditting of performance.            Ward/Departmental performance will                 Board to be improved.
        environment.                                               Facilites      with internal systems of risk       Assurance reporting to               promote performance improvement
                                                   yellow                         assessment/evaluation of            Health and Safety                    transparently. Action: D.Hastings                                          1.1 Rolling out
                                            red                                   performance.                        Committee.                                                                              of new Health & Safety Policy
                                                                                                                                                                                                              through Health and Safety Action
                                                                                                                                                                                                              Plan will improve local accountability
                                                                                                                                                                                                              & ownership of local performance.
                                                                                                                                                                                                              Action: D.Hastings


                                                                                                                                                                                                                       1.2. 09/10 Fire protection
          S4BH - c20a - non-                                                      2. External inspection /            2. Regulating Authorities
          compliant 08/09                                                         reviews of performance from         inspection and audit reports.
                                                                                  regulating authorities

     3e Failure to reduce C diff            tbc      tbc        Acting            1. Infection control action plan 1. Audit of infection control           1.1 Recruitment of dedicated infection
        rates as per target                                                                                        polices & infection rates               control doctor.
                                                                                                                   monitored by EMT, HICC,
                                                                                                                   Trust Board                                       1.2 Audit data of antibiotic
          S4BH - C4a Compliant                                                                                                                             prescribing policy.


      3f Failure to meet local              tbc      tbc        Acting            1. Infection control action plan 1. Audit of infection control           1.1 Recruitment of dedicated infection
         MRSA bacteraemia                                                                                          poliices and infection rates            control doctor.
         target                                                                                                    monitored by EMT, HICC,
                                                                                                                   Trust Board                                          1.2 Audit of suppression
                                                                                                                                                           therapy of MRSA colonised patients.

                                                                                                                                                                                             1.3 Audit of
          S4BH - C4a
          Compliant 08/09

    3g    Provide evidence                  tbc      tbc           Acting         1. Care bundles specifically        1.1 Appropriately timed              1.1 Training packages linked to all care           1.1 Review of audit programme
          based care bundles                                     Director of      aimed at reducing infection         regular audit.                       bundles need to be reviewed - May '09              necessary - May '09
          which aim to promote                                    Nursing,                                                           1.2
          best practice and                                      Midwifery &                                          Monitoring of audit at
          minimise risk to patients                             AHPs /                                                monthly Zero Tolerance
                                                                                                                      meeting
          S4BH - C5a - Non
          compliant 08/09


            Objective 4) To make substantial progress in implementing the Integrated Governance Strategy in order to ensure safe,
                                         high-quality care and full compliance with S4BH standards




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    Risk Principle Risks by Key  Risk              Residue Lead Director           Key Controls                        Assurances on Controls               Gaps in Controls and Actions                       Gaps in Assurances and Actions
     Ref Areas             What Scoring            Risk                               What controls / systems are in                        Where do we                          Where are we failing to put            Where we are failing to gain
           could prevent this objective               Impact     Accountable for     place to secure delivery of the   gain proof / outcomes our controls   effective controls/systems in place? What action      assurance/proof that the controls are
                 being achieved?          Impact            X    management of                 objective?                         are effective?                               needs taking?                      effective? What action needs taking?
                                              X    Likelihood         risk

     4a Corporate Records                 4x3      4x1           Dir of Health     1. There is in place an             1. Through the realisation of 1. Delay into 09/10 regarding compliance No gaps currently identified
        leadership sought                                    =        Info         agreed Integrated                   the action plan.              of C9. Action:
        within the Integrated             = 12     4                               Governance action plan that                1.2 EMT review
        Governance structure                                                       will implement the required         Integrated Governance
        (required for standard             amber    green                          structure.                          action plan every two weeks
        C9 compliance)
          S4BH - C9 - non
          compliant 08/09
     4b Risk of failing to                  tbc        tbc        Acting Med       1. EMT regular review of            1. EMT action plan is                No gaps currently identified                       No gaps currently identified
        implement the                                              Director        progress with committee             monitored on fortnightly
        Integrated Governance                                     (Quality &       structures and HR                   basis
        Strategy                                                   Strategy)
          S4BH - C7a&c Non
          Compliant 08/09
          D3 - not part of
          declaration
     4c Organisational                      tbc        tbc       Acting Dir of     1.                           1. Planned internal audit                   1. Ongoing development of the CLIP                 No gaps currently identified
        Learning - failure to                                      Nursing /       Complaints/Legal/Incidents/P review                                      reports and mortality review processes
        learn from incidents,                                     Acting Med       ALS (CLIP) reports to                                                    with consideration of best practice in
        and external reviews                                      Dir (quality     Divisions, Mortality Review,                                             other organisations
                                                                 and strategy)

          S4BH - C1a -                                                             2. Action plans developed           1. Annual performance                No gaps currently identified                       1. Board and EMT to review action
          Compliant 08/09                                                          following external                  checks & external reviews                                                               plans arising from external reviews
                                                                                   reviews/reports                                                                                                             e.g. S4BH, NHSLA, ALE.

     4d Failure to implement                tbc        tbc        Acting Med       1. Guidelines/Alerts Steering       1. Planned internal audit            1. Every Specialty needs an annual                 1. Review of the governance
        new guidance e.g.                                          Director        Process with implementation         review, Divisional                   governance plan and clinical audit plan.           reporting processes from Divisions to
        NICE, NSFs leading to                                     (Quality &       at Divisional level                 governance reporting                 Action:P.Upton / Clinical Governance               EMT. Action: P.Upton
        poor quality care                                          Strategy)                                           through performance                  Leads
                                                                                                                       reviews
          S4BH - C5a - Non
          compliant 08/09
     4e Failure to develop                  tbc        tbc       Acting Dir of     1. Governance team working 1. Integrated Governance                      1. These are new requirements. Need       Further liason with national bodies,
        quality indicators and                                    Nursing &        with Divisions to keep them Committee, EMT and Board                     for the governance team to have           SHA and PCT to determine what is
        to publish a Quality                                      Therapies /      informed of the required                                                 appropriate focus & resources to deliver. required of RCHT. Action:
        Account                                                   Acting Med       information                                                              Action:
                                                                 Dir (Quality &
                                                                   Strategy)
          S4BH - C7a&c - Non
          Compliant 08/09

      4f Risk of delivering                 tbc        tbc        Acting Med       1. RCHT has joined the        1. External review of        1. EMT monitoring of RCHT position.                              1. Lack of patient outcome data
         unsafe clinical care                                      Director        Patient Safety First Campaign progress with the 5          Action: P.Upton                                                  within the organisation. Introduction
                                                                  (Quality &                                     interventions that come with                                                                  of PROMS and improved outcome
                                                                   Strategy)                                     the campaign                                                                                  data. Action:




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    Risk Principle Risks by Key  Risk              Residue Lead Director          Key Controls                        Assurances on Controls               Gaps in Controls and Actions                       Gaps in Assurances and Actions
                                  tbc                 tbc
     Ref Areas             What Scoring            Risk                              What controls / systems are in                        Where do we                          Where are we failing to put            Where we are failing to gain
           could prevent this objective               Impact    Accountable for     place to secure delivery of the   gain proof / outcomes our controls   effective controls/systems in place? What action      assurance/proof that the controls are
                 being achieved?          Impact            X   management of                 objective?                         are effective?                               needs taking?                      effective? What action needs taking?
                                              X    Likelihood        risk

          S4BH - C1a -
          Compliant 08/09
    4g    Appropriate leadership            tbc      tbc          Acting          1. Structure with appropriate       1.1 Nursing, Midwifery &             1.1 Review of current Nursing, Midwifery 1.1 Membership will change with
          ability & capacity within                             Director of       career progression for senior       AHP Cabinet - senior                 and AHP structures necessary to provide review of the structures.
          the Nursing, Midwifery                                 Nursing,         levels of staff and associated      governing body for                   the senior leadership linked closely with
          & AHP workforce -                                     Midwifery &       governing framework.                Professions.                         divisions
          linked into the                                          AHPs                                                 1.2 Nursing, Midwifery &
          development of the                                                                                          AHP Board - senior
          Divisions as 'self-                                                                                         operational teams for
          standing business                                                                                           Professions
          units'.
          S4BH - C5b -                                                            2. Clear and understood             2.1 Clear, robust job                2.1 Review of current Nursing, Midwifery           2.1 New job descriptions to be drawn
          Compliant 08/09                                                         expectations of staff at all        descriptions.                        &AHP structures necessary to provide               up following the review of the
          C11a - Non compliant                                                    senior levels within the                2.2 KSFs at every level.         the senior leadership linked closely with          Nursing structure 2.2 Accomanying
          08/09                                                                   Nursing, Midwifery& AHP                   2.3 Yearly appraisal for       divisions                                          KSF will need to be completed
                                                                                  workforce                           all staff
    4h    Effective nursing                 tbc      tbc          Acting          1. Robust nursing                   1.1 SAP documentation                1.1 The current nursing documentation is 1.1 Current SAP document does not
          assessments of all                                    Director of       documentation - inlcusive of                                             poorly configured and is currently being facilitate effective use & is being
          patients                                               Nursing,         all assessments necessary                                                reviewed - draft mock replacement just   reviewed
                                                                Midwifery &       for the effective assessment                                             printed and being consulted on by senior
                                                                   AHPs           of all patients                                                          team.
          S4BH - D2b - Not                                                        2. Programme of Quality             2.1 Essence of Care                  2.1 The current programme does not                 2.1 Current documentation does not
          assessed as part of                                                     Nursing Metrics                     Benchmarking                         address all areas necessary to satify              allow for assessment of all areas of
          declaration                                                                                                     2.2 Action plans                 S4BH requirements - all benchmarking               care necessary to appraise for all
                                                                                                                      following benchmarking               documentation being revised into a new             S4BH requirements - therefore
                                                                                                                                                           programme of Nursing Quality Metrics               cannot provide the Board with
                                                                                                                                                                                                              complete assurance around nursing
                                                                                                                                                                                                              quality - all benchmarking
                                                                                                                                                                                                              documentation being revised

                Objective 5) To ensure robust plans are in place for the Trust's role in responding to health emergencies, including
                                                                    pandemic flu.
     5a Ensure sufficient                 5x3      5x1           Director of      1. Resilience Steering group 1.Resilience Steering group 1. Coverage & depth of business                                    1. Improve reporting performance
        Business Continuity                 = 15         =5      Estates &                                     & ToR ensures controls are continuity planning to be developed                                 through Resilience Steering Group to
        Planning is in place to                                   Facilites                                    functioning effectively & can                                                                  Integrated Governance Committee
        adequately respond to               red    yellow                                                      swiftly identify and respond
        unplanned events.                                                                                      to any gaps


          S4BH - C24 - Non                                                        2. Flu Pandemic Policy
          compliant 08/09
                                                                                  3. Active particpation in South

                                                                                  4. West Emergency Planning
                                                                                  Group




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    Risk Principle Risks by Key  Risk              Residue Lead Director          Key Controls                        Assurances on Controls               Gaps in Controls and Actions                       Gaps in Assurances and Actions
     Ref Areas             What Scoring            Risk                              What controls / systems are in                        Where do we                          Where are we failing to put            Where we are failing to gain
           could prevent this objective               Impact    Accountable for     place to secure delivery of the   gain proof / outcomes our controls   effective controls/systems in place? What action      assurance/proof that the controls are
                 being achieved?          Impact            X   management of                 objective?                         are effective?                               needs taking?                      effective? What action needs taking?
                                              X    Likelihood        risk

                                                                                  5. Business Continuity
                                                                                  Planning Policy & procedures

                                                                                  6. Major Incident Plan

     5b Failure to have robust              tbc      tbc          Acting          1. Divisional plans for health
        plans in place for                                      Director of       emergencies including
        clinical and business                                    Nursing,         pandemic flu. Divisional and
        processes                                               Midwifery &       Corporate plans for business
                                                                   AHPs           continuity
          S4BH - C24 - Non
          Compliant 08/09




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    Risk Principle Risks by Key  Risk              Residue Lead Director          Key Controls                        Assurances on Controls               Gaps in Controls and Actions                       Gaps in Assurances and Actions
     Ref Areas             What Scoring            Risk                              What controls / systems are in                        Where do we                          Where are we failing to put            Where we are failing to gain
           could prevent this objective               Impact    Accountable for     place to secure delivery of the   gain proof / outcomes our controls   effective controls/systems in place? What action      assurance/proof that the controls are
                 being achieved?          Impact            X   management of                 objective?                         are effective?                               needs taking?                      effective? What action needs taking?
                                              X    Likelihood        risk


    Overarching Objective - ACHIEVING FINANCIAL HEALTH
            Objective 6) To achieve financial health, through meeting all financial targets, including delivering a financial surplus of
                                  £8.3 million, and thereby securing a sustainable financial future for the Trust
     6a Failure to deliver      5x3      5x2                    Dir of Finance 1. Robust budget setting               1. Monthly board and                 1. Divisions have yet to sign off budgets          1. Until the Trust can evidence
        financial targets in         =       =                                 process for 2009-10 -                  finance committee reports            for 09-10, action is in place to ensure full       operating in financial balance month
        2009-10 which is to     15      10                                     detailed budgetary control             on financial performance.            sign off across the whole Trust. There is          on month, then a gap in assurance to
        achieve a surplus of        red                                        framework in place,                    Internal and External Audit          also a need to continue urgently with              the Board will remain.
        £8.3m. This will result          amber                                 budegtary control manual,              reports.                             service improvement programmes in
        in a WEAK                                                              scheme of delegation,                                                       kernoflex, ward staffing, rostering and
        assessment for Use of                                                  standing financial procedures                                               capacity and demand to resolve pay
        Resources, failure to                                                  and financial procedures.                                                   pressures which were continuing at the
        make loan repayments,                                                                                                                              end of 08-09. These projects are all in
        intervention and                                                                                                                                   place & reported via the Service
        consequential loss of                                                                                                                              Improvement Board. Action: SIP:
        confidence in Trust
        Board.

          S4BH - C7d -                                                            2. Monthly reports to Board         2. Monthly board and                 2. Review of financial Board reporting
          declaration n/a;                                                                                            finance committee agendas            proposed for 09-10 to ensure the Board
          assessed by other                                                                                           and reports.                         explicitly understands the financial
          measures (ALE)                                                                                                                                   position of the Trust. Action:
                                                                                                                                                           J.Teape/C.Cale:May 09
                                                                                  3. Finance Committee                3. Monthly finance                   3. Review of financial reporting proposed
                                                                                  established to oversee              committee agendas and                for 09-10 to ensure the Finance
                                                                                  details of financial                reports and minutes.                 Committee explicitly understands the
                                                                                  performance                                                              financial position of the Trust.
                                                                                                                                                           Action:J.Teape/C.Cale:May 09

                                                                                  4. Internal and External Audit 4. Internal and External
                                                                                  programme in place             Audit reports &
                                                                                                                 recommendations.
                                                                                  5. Capital management               5. Capital Management                                                                   5. The 09-10 capital programme is
                                                                                  group in place to review            Group papers, minutes &                                                                 predicated on receiving year 2
                                                                                  capital expenditure & ensure        agendas.                                                                                funding for the St Michaels Business
                                                                                  overall programme is                                                                                                        Case & the Sexual Health Hub (total
                                                                                  managed within resources                                                                                                    £4.4m). This has not been confirmed.
                                                                                  available                                                                                                                   Until confirmation the Capital
                                                                                                                                                                                                              Programme will need careful review
                                                                                                                                                                                                              to ensure funds are not committed
                                                                                                                                                                                                              until financing is clear. Action to
                                                                                                                                                                                                              pursue the DH early in year for
                                                                                                                                                                                                              release of year 2 funding. Action:
                                                                                                                                                                                                              C.Cale:Q1 09/10




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    Risk Principle Risks by Key  Risk              Residue Lead Director          Key Controls                        Assurances on Controls               Gaps in Controls and Actions                       Gaps in Assurances and Actions
     Ref Areas             What Scoring            Risk                              What controls / systems are in                        Where do we                          Where are we failing to put            Where we are failing to gain
           could prevent this objective               Impact    Accountable for     place to secure delivery of the   gain proof / outcomes our controls   effective controls/systems in place? What action      assurance/proof that the controls are
                 being achieved?          Impact            X   management of                 objective?                         are effective?                               needs taking?                      effective? What action needs taking?
                                              X    Likelihood        risk

                                                                                  6. Business Case Review             6. Business Case Review
                                                                                  group in place to review all        Group ToR, agendas &
                                                                                  new developments.                   minutes.
                                                                                  7. Divisional performance           7. Divisional performance            7. Review of reporting proposed for 09-
                                                                                  reviews in place to review          reviews and reports.                 10. Action: J.Teape / V.Howell
                                                                                  financial performance on a
                                                                                  monthly basis.
                                                                                  8. Detailed financial skills        8.1 Finance skills
                                                                                  development strategy in             development strategy for 09-
                                                                                  place.                              10.                   8.2
                                                                                                                      Finance Skills Development
                                                                                                                      attendance records.

                                                                                  9. Revised internal control 9.1 Weekly Executive
                                                                                  processes approved by the   Vacancy Review Group.
                                                                                  Executive Team during 08-09                 9.2 Monthly
                                                                                  in place.                   agency spend reports to the
                                                                                                              Board.
                                                                                  10. Service Improvement     10. See objective 2 above                            10. See objective 2 above                        10. See objective 2 above
                                                                                  programme

     6b Failure to deliver                 4x4     4x3    Dir of Finance 1. Monthly reports to Board                  1. Monthly reports to Board          1. There are a number of significant               1. Until improvements in the
        adequate                          =16       = 12                 and Finance Committee on                     and Finance Committee on             actions required to improve controls at all        outcomes and performance can be
        improvements to the                                              performance against Public                   performance against Public           levels; the actions set out in the report to       identified there remains a gap in
        public sector payment               red     amber                Sector Payment Policy.                       Sector Payment Policy                Finance Committee (Mar 09) include                 assurance to the Board. The action
        target resulting in the                                               Public Sector Payment                                                        improvements to the procurement                    plans set out in the gaps in control
        Trust being a poor                                               Policy Action Plan reported to                                                    process, improvements to the                       section should provide assurance but
        payer, loss of                                                   Finance Committee in March                                                        authorisation process and improvements             only when they translate into
        reputation and failure                                           2009                                                                              to the payment process. Is being                   improved performance; until this is
        to support the local                                                                                                                               monitored via the Finance Committee.               demonstrated this remains an area
        economy.                                                                                                                                           Action: J.Teape: Ongoing (review Q1)               for ongoing review at Board level.
             S4BH                                                                                                                                                                                             Gaps in controls being monitored by
                                                                                                                                                                                                              the Finance Committee. Action:
                                                                                                                                                                                                              J.Teape: Ongoing (review Q1)
          S4BH - C7d -
          declaration n/a;
          assessed by other
          measures (ALE)

     6c Failure to fully                  5x3       5x3         Dir of Health     1. HRG4 Implementation              1.1 Through full & accurate          1. There are several areas of HRG4                 No gaps currently identified
        implement HRG4                    = 15     =15               info         Project Team is fully in place      data recording & clinical            where the infrastructure (Receiption,
                                                                                  and managing all aspects of         coding on all relevant               Ward Clerks) is not fully in place. Action:
                                           amber   amber                          the implementation.                 clinical activity
                                                                                                                      1.2 Progress is reported
                                                                                                                      through to the SIP Board




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                                          5x3       5x3
                                  15
    Risk Principle Risks by Key = Risk             =15
                                                   Residue Lead Director          Key Controls                        Assurances on Controls               Gaps in Controls and Actions                       Gaps in Assurances and Actions
     Ref Areas             What Scoring            Risk                              What controls / systems are in                        Where do we                          Where are we failing to put            Where we are failing to gain
           could prevent this objective    amber    amber
                                                     Impact     Accountable for     place to secure delivery of the   gain proof / outcomes our controls   effective controls/systems in place? What action      assurance/proof that the controls are
                 being achieved?          Impact            X   management of                 objective?                         are effective?                               needs taking?                      effective? What action needs taking?
                                              X    Likelihood        risk

          S4BH - C7d -                                                            2. Consistent and                   2. See above                         2.1. Outcome forms not due to be fully in          No gaps currently identified
          declaration n/a;                                                        appropriate processes in                                                 place until June 2009.
          assessed by other                                                       place for patient                                                        2.2 Consistent documented processes
          measures (ALE)                                                          administration; redesigned                                               not yet fully implemented.
                                                                                  outcome forms fully
                                                                                  implemented.
                                                                                  3. A number of discrete             3. See above                         3.1 Escalation is correctly occuring   No gaps currently identified
                                                                                  areas of the Trust not                                                   through the HRG Implmenetation Project
                                                                                  progressing HRG4 coding
                                                                                  (I.e. Diagnostic Imaging
                                                                                  (mapping CRIS to CACI;
                                                                                  GUM needs a SUS feed;
                                                                                  Neonatal HDU needs CACI
                                                                                  feed)
                                                                                  4. Awareness programme is           4. See above                         4. There is a poor level of attendance      No gaps currently identified
                                                                                  being systematically rolled                                              from Juior Doctors, raised to the
                                                                                  out through the Trust.                                                   attention od the Medicxal Director. Action:




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    Risk Principle Risks by Key  Risk              Residue Lead Director          Key Controls                        Assurances on Controls               Gaps in Controls and Actions                       Gaps in Assurances and Actions
     Ref Areas             What Scoring            Risk                              What controls / systems are in                        Where do we                          Where are we failing to put            Where we are failing to gain
           could prevent this objective               Impact    Accountable for     place to secure delivery of the   gain proof / outcomes our controls   effective controls/systems in place? What action      assurance/proof that the controls are
                 being achieved?          Impact            X   management of                 objective?                         are effective?                               needs taking?                      effective? What action needs taking?
                                              X    Likelihood        risk



    Overarching Objective - STRATEGIC PLANNING AND RELATIONSHIPS

            Objective 7) To develop a medium-term plan for the Trust's future development which will identify clinical strengths and
             key priorities. It is likely that there will be a number of different dimensions to this plan including a clinical strategy, a
             teaching, education and research strategy, a consideration of the Trust's position in the local economy; including its
                       environmental impact and the estate, infrastructure and investment to deliver these strategic goals
     7a Failure to implement              5x2      3x2          Director of       1. Trust Estate Strategy            1. Development Control               1.1 Development of Clinical Strategy               1. Enhanced outcome reporting to
        appropriate Estate                  = 10     =6         Estates and                                           Plans and other supporting           required to allow further detailing of             Board. Action: D.Hastings
        Strategy                                                  Facilites                                           documents to the Strategy            Estates Plans. Action: P.Upyon
                                                                                                                                                                                1.2 Further
                                           amber   yellow                                                                                                  development of KPI's to allow effective
                                                                                                                                                           monitoring of Estate Strategy outcomes
                                                                                                                                                           required. Action: D.Hastings
          S4BH - C20a - Non
          Compliant 08/09

    7b    Absence of clinical               tbc      tbc           Acting         1. Development of a clinical    1. Board approval of the                 1. Consultation on the developing clinical No gaps currently identified
          strategy inhibits                                       Medical         strategy that can assist in the clinical strategy                        strategy with the wider clinical
          service planning and                                    Director         management and planning                                                 community and RCHT partners. Action:
          development                                           (quality and      processes                                                                P.Upton
                                                                  strategy)
          S4BH - C7a&c - Non
          Compliant 08/09

    7c    Absence of teaching,              tbc      tbc           Acting         1. Development of these             1. Board approval of the             1. Consultation with key partners. Action: No gaps currently identified
          education and                                           Medical         strategies                          clinical strategy                    P.Upton
          research strategy                                       Director
          results in RCHT                                       (quality and
          missing developmental                                   strategy)
          opportunities
          S4BH - C11c -
          Compliant 08/09

            Objective 8) To strengthen working relationships with other health and social care organisations in Cornwall in order to
                                                          improve patient outcomes
                                                                                                                           No Risks Currently Identified




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    Risk Principle Risks by Key  Risk              Residue Lead Director          Key Controls                        Assurances on Controls               Gaps in Controls and Actions                       Gaps in Assurances and Actions
     Ref Areas             What Scoring            Risk                              What controls / systems are in                        Where do we                          Where are we failing to put            Where we are failing to gain
           could prevent this objective               Impact    Accountable for     place to secure delivery of the   gain proof / outcomes our controls   effective controls/systems in place? What action      assurance/proof that the controls are
                 being achieved?          Impact            X   management of                 objective?                         are effective?                               needs taking?                      effective? What action needs taking?
                                              X    Likelihood        risk



    Overarching Objective - DEVELOPING THE INFRASTRUCTURE

             Objective 9) To strengthen information systems and analysis in the Trust to support service transformation, including
                              moving towards understanding individual patient costs, outcomes and experiences.
     9a Failure of Trust to       4x3    4x2                    Dir of Finance 1. Patient Level Costing               1.1 Patient Level Costing            None identified at this stage, project has         None identified at this stage, project
        adequately understand                                                  Project Board                          Project Board agendas and            commenced and is on track.                         has commenced and is on track.
        the costs of individual     = 12 = 8                                                                          minutes.
        patients, services, and                                                                                                  1. 2 Service
        the income generated,             yellow                                                                      Improvement Programme
        resulting in an inability  amber                                                                              project board
        to manage service                                                                                                              1.3 Project
        lines effectively,                                                                                            Initiation Document
        increasing the                                                                                                                1.4 Project
        possibility of not                                                                                            Plan and timetable
        delivering financial                                                                                                   1.5 Finance
        targets & taking sound                                                                                        Committee updates
        decisions based on
        high quality financial
        information. Further
        risk that income will not
        appropriately collected



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

     9b Informatics capabilities          4x3     4x2     Dir of Health           1. Information Business Case 1. Informatics Programmes                   1. Information Business Case not yet               1. Escalation route yet to be agreed
        and capacity not                     = 12              info               presented & supported at     fully completed (particularly               approved. Action: R.Johnson                        from these Informatics Boards
        developed throughout                      =8                              leadership                   Service Line Reporting                                                                         Action: R.Johnson / M.Haynes
        the Trust                          amber                                                               project)
                                                   yellow
          S4BH - D6 - not
          included in
          declaration
     9c System infrastructure             4x3      4x2          Dir of Health     1. Appropriate allocation of   1.1 Service Line Reporting No gaps currently identified                                      No gaps currently identified
        not developed to                  = 12     =8                info         capital monies to deliver      project on target
        required level to                                                         required system infrastructure               1.2 Any Issues
        support Patient Level              amber                                                                 (gaps) are picked up by the
        Costing                                    yellow                                                        SLR Project Board
          S4BH - C7b - Non
          compliant 08/09




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    Risk Principle Risks by Key  Risk              Residue Lead Director          Key Controls                        Assurances on Controls               Gaps in Controls and Actions                       Gaps in Assurances and Actions
     Ref Areas             What Scoring            Risk                              What controls / systems are in                        Where do we                          Where are we failing to put            Where we are failing to gain
           could prevent this objective               Impact    Accountable for     place to secure delivery of the   gain proof / outcomes our controls   effective controls/systems in place? What action      assurance/proof that the controls are
                 being achieved?          Impact            X   management of                 objective?                         are effective?                               needs taking?                      effective? What action needs taking?
                                              X    Likelihood        risk

     9d Failure to get                      tbc      tbc           Acting         1. Divisional management            1. Staff survey                      1. Need for development of the divisional No gaps currently identified
        appropriate information                                   Medical         teams and information                                                    management structures
        flow from Board to                                        Director        dissemination through them
        Ward, and Ward to                                       (operations)
        Board
          S4BH - C7a&c - Non
          compliant 08/09
          D3 - not part of
          declaration

            Objective 10. To ensure the Trust meets the pledges to staff in the NHS constitution around quality work, safety and
           wellbeing, learning and development and involvement and partnership, thus improving staff satisfaction and supporting
                                                  staff in delivering high quality services.
     10a Lack of capacity within          4x3      4x2           Director of      1. Draft revised HR                 1. LDP Business Planning             1.Monitoring the effectiveness of the new 1. Report to Trust Board with an
         the HR Structure                  = 12    =8             Human           Directorate Structure to            process;                             structure once implemented. Action: JP    implementation plan. Action: JP
                                                                 Resources        ensure it is fit for purpose,
                                           amber    yellow                        and aligned with Divisional &
                                                                                  Delivery
          S4BH - C11a - Non                                                       2. Successful Business              2. Agreed additional      2. Pending consultation within the HR      No Gaps currently identified
          compliant 08/09                                                         Planning outcome to achieve         Resources required via    Structure and Business Partners, delay
                                                                                  additional financial resources      External Jointly          in recruitment to vacant posts. Action: JP
                                                                                  internally through OD budget        Commissioned Review; the
                                                                                  to support additional               RCT Trust Board annual HR
                         Joint                                                    infrastructure posts;               report 2008; Strategic
          Independent Review                                                                                          Resources Committee,
          Report Para [68]                                                                                            2008.
                                                                                  3. Securing 1 year fixed-term 3. Business Plan submitted                 3. Pending new posts being AFC                     No Gaps currently identified
                                                                                  funding from SHA to support and accepted by SHA,                         banded; Finalisation of internal
                                                                                  Workforce Development         March 2009.                                consultation with Business Partners.


     10b Failure to achieve &             4x3      4x2           Director of      1. Standard Leads in place          1. Regular Top Team Leads 1. Unstructured framework, with clear                         No Gaps currently identified
         deliver Corporate                 = 12    =8             Human                                               meetings with Director of HR deadlines and dates for leads to report
         Compliance within                                       Resources                                                                         into. Action: JP
         Human Resources                   amber    yellow
         [S4BH]

          S4BH - C7e -                                                            2. Action & Development             2. Reviewed at TT meetings; 2. Review a\nd develop documentation                        No Gaps currently identified
          Compliant 08/09                                                         Plans for 09/10 all standards                                   for monitoring and review.
          C8a - Compliant
          C8b - Non compliant                                                     3. Monitor & Review                 Top team & EMT action                No Gaps currently identified                       No Gaps currently identified
          C10a - Compliant                                                        standards via Directorate TT        plans; EMT assurance
          C10b - Compliant                                                        Meetings; improved rigour &         meetings; Board scrutiny &
          C11a -Non Compliant                                                     review / assessment at EMT;         involvement of assurance
          C11b - Compliant                                                        & Governance Committee              process
          C11c - Compliant




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    Risk Principle Risks by Key  Risk              Residue Lead Director          Key Controls                        Assurances on Controls               Gaps in Controls and Actions                       Gaps in Assurances and Actions
     Ref Areas             What Scoring            Risk                              What controls / systems are in                        Where do we                          Where are we failing to put            Where we are failing to gain
           could prevent this objective               Impact    Accountable for     place to secure delivery of the   gain proof / outcomes our controls   effective controls/systems in place? What action      assurance/proof that the controls are
                 being achieved?          Impact            X   management of                 objective?                         are effective?                               needs taking?                      effective? What action needs taking?
                                              X    Likelihood        risk

     10c Failure to achieve      4x3    4x2                      Director of      1. Appraisal Policy                 1. Evidence raised at                1. Absence of new Divisional                       No Gaps currently identified
         Standards for Better     = 12 =8                         Human                                               Divisional Performance               Performance review arrangements.
         Health ref. 8b, non                                     Resources                                            Reviews of Appraisal and
         completion of review of  amber yellow                                                                        PDP trajectories                                     1.1.Absence of full HR
         appraisal                                                                                                                                         Score card
         documentation
          S4BH - C8b - Non
          compliant 08/09



                  Objective 11) To minimise the environmental impact of the Trust's activities and ensure sustainable development.
     11a Failure to implement             3x5      3x2           Director of      1. Draft Carbon Reduction           1. Implementation of                 1. Carbon Reduction Strategy & Action              1. Progress reporting to Board on
         appropriate Carbon                 = 15   =6            Estates &        plan reviewed by Strategic          Carbon Reduction Initiative          Plan to be approved by Board. Action:              implentation of action plan. Action: D.
         Reduction Strategy                                       Facilites       Resources Commitee                  across Trust                         D.Hastings / Q1)                                   Hastings
         leading to                        amber    yellow
         unacceptable medium
         term strategy /
         performance
          S4BH - C21 -
          Compliant




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    Risk Principle Risks by Key  Risk                    Residue Lead Director          Key Controls                        Assurances on Controls               Gaps in Controls and Actions                       Gaps in Assurances and Actions
     Ref Areas             What Scoring                  Risk                              What controls / systems are in                        Where do we                          Where are we failing to put            Where we are failing to gain
           could prevent this objective                     Impact    Accountable for     place to secure delivery of the   gain proof / outcomes our controls   effective controls/systems in place? What action      assurance/proof that the controls are
                 being achieved?          Impact                  X   management of                 objective?                         are effective?                               needs taking?                      effective? What action needs taking?
                                              X          Likelihood        risk


            Objective 12) To continue to strengthen management and planning processes in the Trust, developing the organisation
                                          in preparation for an application for Foundation Trust status.
     12a Delivery on                      5x5            5x1              CEO           1. Chairman's Progress              1.1 ToR details                      This Committee will oversee                        No gaps in assurances have been
         recommendations                             =                                  Committee has been                  membership, frequency,               implementation of the 27 review                    identified. The Chairman's Progress
         within the Independent           25              =5                            created. It is due to be            and Commitee's 2 prime               recommendations. These 27 gaps in                  Committee will seek internal
         Review of                             red                                      conveened 21st May.                 objectives                           control sit under 4 core themes:                   assurances on progress to ensure
         Management and                                  yellow                                                                                                                                                     they are effective in identifying any
         Governance at RCHT                                                                                                                                                                                         gaps in implementation.
                                                                                                                                                                                       1.1 Financial
                                                                                                                                                                 management & performance
                                                                                                                            1.2 Committee action plan
          S4BH - C7a&C - Non                                                                                                provides assurances of
          compliant 08/09



     12b Compliance with                       tbc         tbc          Acting
         Standards For Better                                         Director of
         Health is supported by                                        Nursing,                                  Controls and assurances to be confirmed by the acting DoN
         a robust internal                                            Midwifery &
         assurance process                                               AHPs
          S4BH - c7a&c non-
          compliant 08/09




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

				
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