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					                                                            South Warwickshire General Hospitals NHS Trust
                                                                        Guide to Terms Used




Column Item             Comment

                        Definition: A risk is a POTENTIAL event or intervening factor which MIGHT in the future failure to To return to Objective either click on
D        Risks          achieve (or fully achieve) an objective. Note that failure itself is not a risk - it is the potential required objective 'tab' or scroll to
                        EFFECT of a risk ocurring or materialising.                                                           bottom of page and click on hyperlink


                        For each objective, enter a brief description of each significant risk relating to that objective. There
                        may be more than one risk for each objective (a, b, c etc) - add or delete rows as required.
         Initial Risk   Definition: The initial (or 'inherent') risk level is assesses as though the Trust was taking no action
EFG
         Rating         to control or mitigate the risk. The 'residual' risk will be assessed later.


                        Assess the consequence and likelihood of each risk, on a scale of 1 to 5 (see rating scales below).
                        The spreadsheet automatically calculates the total (compound) risk level from these two entries.

         Residual
KLM
         Risk Rating
                        Definition: The residual risk level is assessed …………………

         Consequence rating (severity of impact if it occurs)
                       l No injury or identifiable damage
         1-            l No disruption to service or the organisation
         Insignificant l Financial implications are negligible
                       e.g. tripping, file falling & hitting someone, spills of non hazardous liquids
                       l Mild injury (will probably resolve in less than 1 month)
         2-            l The impact would threaten the efficiency of some aspects of the organisation

         Minor          l Some financial implications, e.g. absence from work <3 days
                        l Some injury (emotional, psychological or physical), ill health, damage, or loss of function likely
                        to resolve within one year
         3-             l Disruption to organisation could be managed
         Moderate       l Moderate financial implications (>£50K)
                        e.g. RIDDOR reportable injury, local adverse publicity, missing claim file
                        l Serious injury (emotional, psychological or physical), ill health, damage, or loss of function
                        possibly with prolonged disability
         4-             l Serious disruption to the organisation




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                                                         South Warwickshire General Hospitals NHS Trust
                                                                     Guide to Terms Used




         Major       l High financial implications (>£500K)
                     e.g. large section of roof falling in, local adverse publicity, computer network failure >3 working
                     days, prolonged time off work (>15 days)




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                                                          South Warwickshire General Hospitals NHS Trust
                                                                      Guide to Terms Used




                      l Death or significant permanent disability
         5-           l Organisation unable to function
         Catastrophic l Very high financial implications (>£1million)

                      e.g. large scale fraudulent claims management, national adverse publicity, bomb threat, anything
                      untoward that involves >50 people

         Likelihood rating (probability of occurring)
         1 - Rare     Cannot believe that the event will occur in the foreseeable future
         2 - Unlikely Unlikely that the event will happen
         3 - Likely   This type of event may well happen (e.g. 50/50 chance)                                                      Go Back to Objective 1
         4 - Highly   The event is more likely to happen than not
         Likely                                                                                                                   Go Back to Objective 2
         5 - Certain The event is expected to happen, i.e. at least once in the relevant period                                   Go Back to Objective 3
                                                                                                                                  Go Back to Objective 4
                      Definition: A control is a management process or othere means to prevent the risk event occuring,
H        Controls     or to give an early warning that the risk may be occuring. Or to mitigate the consequences if the risk
                      does occur.                                                                                            Go Back to Objective 5

                      Enter brief details of any control measures that are in place or are being introduced. There may be
                      more than one control for each risk (I, ii, iii etc.) - add or delete rows as required.             Go Back to Objective 6

I        Assurances Definition: An assurance is a means of providing confirmation that a control measure is in place
                    and is effective, e.g an audit or performance report.                                                         Go Back to Objective 7
                      For each control measure, enter brief details of any assurance process that are in place or are
                      being introduced.                                                                                           Go Back to Objective 8

         Positive     Is when a report has been received, whether it is external or internal and the result of that report
J        Assurance    (this can be coded according to the quality of the assurance given i.e.Full, limited, significant, none).
         Gaps in      Comment on areas where there are inadequate control measures in place given the level of risk
N
         Controls     identified.                                                                                                 Go Back to Objective 9
         Gaps in      Comment on areas where there are inadequate evidence that the stated controls (column H) are
O
         Assurance    actually in place and are effective.                                                                        Go Back to Objective 10




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                                                       South Warwickshire General Hospitals NHS Trust
                                                                   Guide to Terms Used




P        Action Plan Action being taken to address the gaps in controls and assurances.




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Sfbh Domain               ID   Principle Objective                                                        Lead Director               Assuring Committees
Safety, Care Environment   1   Continue to implement systems that support Zero Tolerance of Hospital      Medical Director            Clinical Governance
& Amenities                    Acquired Infections
Patient Focus, Accessible  2   Ensure the Trust meets the National 18 week Target set by the              Director of Operations      Finance & Performance
& Responsive Care              Department of Health

Governance                  3 Maintain Financial Stability and implement improved systems                 Director of Finance         Finance & Performance

Public Health               4 Improve processess that supports the Trust's response in the event of a     Director of Operations      Clinical Governance and
                              major emergency                                                                                         Finance & Performance
Governance, Patient         5 Achieve Foundation Trust Status                                             Trust Secretary             Foundation Trust Steering
Focus                                                                                                                                 Group
Governance                  6 Improve Staff involvement in all aspects of the organisation                Director of Human Resources Corporate Affairs

Patient Focus, Clinical     7 Develop and implement new technology to improve efficiency and patient      Director of Development     Finance & Performance
Cost & Effectiveness          care
Patient Focus, Accessible   8 Improve local access to specialist care                                     Director of Development     Corporate Affairs
and Responsive Care

Patient Focus, Accessible   9 Improve the patient and public experience within the Trust                  Director of Development     Clinical Governance and
and Responsive Care,                                                                                                                  Corporate Affairs
Care Environment &
Amenities
Patient Focus, Accessible   10 Improve the supporting administrative systems                              Director of Operations      Corporate Affairs and
& Responsive Care                                                                                                                     Finance & Performance

All Domains                 11 Obtain quality of service rating from the Healthcare Commission of at least Director of Operations     All Assuring Committees
                               'Good' and NHSLA level 2
                                                                                                   South Warwickshire General Hospitals NHS Trust
                                                                                                                Assurance Framework
                                                                                                                                                                                                                                     Objective 1
      Principle Objective 1:                   The Trust will continue to implement systems that support zero tolerance of Hospital Acquired Infections (HAI)

      SfBH Domain                              Safety, Care Environment & Amenities

      Lead Director                            Medical Director

      Assuring Committee                       Clinical Governance Committee



                                                 Initial Risk
                                                                                                                                                                                                                                       Who         When
ID    Risks                                        Rating            Controls                              Assurances                           Positive Assurances               Gaps in Controls   Gaps in Assurance Action Plan
                                                     MAY                                                                                        Identified in Board Reports and
                                                                                                                                                External Assessments


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 234 Failure to follow infection prevention     5     3     15       Training Programme                    Attendance Register of training
     polices and procedures                                                                                courses
                                                                     Zero Tolerance Statement              Reports of Root Analysis
                                                                                                           Investigations:
                                                                     Peripheral Intra-Vascular Access      Audit of Peripheral Intra-Vascular
                                                                     Forms                                 Access Forms
                                                                                                           Infection Prevention Board
                                                                                                           Monthly Minutes
                                                                                                           Trust Board Monthly Minutes
 261 Cleanliness of the environment and         5     3     15       Increased resources dedicated to      Audits of cleaning environment
     equipment does not meet the required                            cleaning and disinfection:
     standards to prevent the spread of
     infection
                                                                     Sterinis Hydrogen peroxide            Report from Hotel Services
                                                                     generators:                           Manager to Infection Prevention
                                                                                                           Board
                                                                     Deep Cleaning Rota for Clinical       Annual PEAT Report
                                                                     Areas:
                                                                     Ward and department managers Key Performance Indicators for
                                                                     given responsibility for           Ward Managers
                                                                     management of cleanliness
                                                                     standards, including equipment, in
                                                                     their own environment



 262 Patients whose discharge is delayed are    5     4     20       Bed Management Policy                 Audit of patient bed movements
     at increased risk of acquiring HCAI

                                                                     Bed Managers                          Number of delayed discharges
                                                                                                           reported
                                                                     Discharge Co-ordinators               Patients are moved into
                                                                                                           community beds or adequate
                                                                                                           nursing home provision in a
                                                                                                           timely manner
                                                                     Regular bed management and
                                                                     discharge planning meetings
                                                                     Director of Operations liaises with
                                                                     PCT in relation to use of
                                                                     community beds




                                                                                                                              Collated by Pat Morris Head of Governance
                                                                                                                                              7/15/2010                                                                                        6
                                                                                                                      South Warwickshire General Hospitals NHS Trust
                                                                                                                                  Assurance Framework
                                                                                                                                                                                                                                                              Objective 1
                                                 Initial Risk
                                                                                                                                                                                                                                                                  Who                When
    Risks                                          Rating            Controls                           Assurances                      Positive Assurances               Gaps in Controls                  Gaps in Assurance Action Plan
                                                     MAY                                                                                Identified in Board Reports and
                                                                                                                                        External Assessments




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263 High bed occupancy reduces time             5     4     20       Updated cleaning regimes and       Ward Audit Clealiness Reports
    available for proper cleaning of beds                            additional cleaning resources to
    between patients                                                 ward areas
                                                                     On-call deep cleaning team        PEAT inspection report;
                                                                     Bed management policy; bed        Audit of Patient Movements
                                                                     management meetings thrice
                                                                     daily:
                                                                     discharge co-ordinators meet with Minutes of discharge meetings
                                                                     operations director to facilitate
                                                                     difficult discharges
                                                                                                       Reported monthly to Clinical
                                                                                                       Governace
                                                                                                       Reported monthly to Infection
                                                                                                       Prevention Board
264 PCT fail to reduce incidence of community   5     5     25       County-wide meeting of DIPCs      Minutes of DIPCs meeting
    HCAI
                                                                     PCT Representative member of       Minutes of IPB meeting
                                                                     Infection Control Board
                                                                     Health protection Agency
                                                                     Representation at Infection
                                                                     Control Team Meetings


265 The Trust fails to introduce MRSA           2     5     10                                          Reported monthly to Clinical                                      Screening method to be used not                     Microbiologists meeting to     Infection Control       30/06/2008
    Screening for all elective patients                                                                 Governace                                                         identifed                                           determine most effective       Consultant
                                                                                                                                                                                                                              screening method
                                                                                                        Reported monthly to Infection                                     Resources yet to be identified                      Logistics meeting to           AGM for Critical         9/30/2008
                                                                                                        Prevention Board                                                                                                      determine how many, when       Care
                                                                                                                                                                                                                              and where
                                                                                                                                                                          Implementation Plan                                 Financial Meeting in Liaison   Trust DIPCs             12/31/2008
                                                                                                                                                                                                                              with the PCT to discuss
                                                                                                                                                                                                                              costs
                                                                                                                                                                                                                              Implementation Plan            AGM for Critical          3/3/2009
                                                                                                                                                                                                                                                             Care




                                                                                                                          Collated by Pat Morris Head of Governance
                                                                                                                                          7/15/2010                                                                                                                              7
                                                                                                                  South Warwickshire General Hospitals NHS Trust
                                                                                                                              Assurance Framework
                                                                                                                                                                                                                                                            Objective 2
    Principle Objective 2:                    The Trust will ensure that it meets the National 18 week target.

    SfBH Domain                               Patient Focus, Accessible & Responsive Care

    Lead Director                             Director of Operations

    Assuring Committee                        Finance & Performance Committee



                                                Initial Risk
                                                                                                                                                                                                                                                                  Who          When
    Risks                                         Rating             Controls                          Assurances                      Positive Assurances               Gaps in Controls                      Gaps in Assurance Action Plan
                                                    MAY                                                                                Identified in Board Reports and
                                                                                                                                       External Assessments


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289 Lack of capacity in the Oral surgery       2     4       8       SLA with UHCW                     Monthly Finance & Performance                                     Outline alternative proposal for if                     Alternative proposal for    Director of       31/08/2008
    service                                                                                            Report                                                            UCHW SLA does not perform                               SLAd                        Operations
                                                                     AGM for General Surgery lead
                                                                     responsibility


290 Implementation of PAS 2.2 may affect       3     4      12       PAS Project Implementation        IT Board monthly
    data quality and reporting for 18 weeks                          Board

                                                                     Project IT Lead, 18week Project
                                                                     Manager


291 Bed availiability in Jan, Feb and March    5     2      10       Bed Capacity Plan                 Monthly Report to Finance &                                       Bed capacity plan highlights                            Proposal for incresaing     Director of       30/06/2008
    may lead to elective cancellations                                                                 Performance (Cancellations,                                       limited bed capacity available                          available bed capacity      Development
                                                                                                       LOS, Bed Occupancy)
                                                                     Discharge Planning Team
                                                                     Care close to home multi agency
                                                                     working party
                                                                     Emergency flows and lengths of                                                                                                                              Length of Stay reduction    Director of
                                                                     stay                                                                                                                                                        programme                   Operations




                                                                                                                     Collated by Pat Morris Head of Governance
                                                                                                                                      7/15/2010                                                                                                                            8
                                                                                                                           South Warwickshire General Hospitals NHS Trust
                                                                                                                                       Assurance Framework
                                                                                                                                                                                                                                       Objective 3

    Principle Objective 3:                       The Trust will maintain financial stability and implement improved systems of work

    SfBH Domain                                  Governance

    Lead Director                                Director of Finance

    Assuring Committee                           Finance and Performance Committee




                                                   Initial Risk        Controls                              Assurances                         Positive Assurances               Gaps in Controls   Gaps in Assurance
                                                                                                                                                                                                                                        Who      When
    Risks                                            Rating                                                                                                                                                              Action Plan
                                                       MAY                                                                                      Identified in Board Reports and
                                                                                                                                                External Assessments
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299 Contractual Fines for failure to achieve      5     3     15       Increased cleaning and isolation      Number of cases below trajectory
    Cdiff and 18 week targerts                                         facilities for Cdiff. New trustwide   to be reported monthly to Trust
                                                                       anitibiotic policy.                   Board (for both areas) e.g
                                                                                                             number of hospital acquired
                                                                                                             C.Diff cases reported monthly by
                                                                                                             Medical Director


                                                                       18 Weeks - weekly workload            Monthly board reporting into 18
                                                                       planning meetings to manage           week performance from Director
                                                                       demand v capacity.                    of Operations on number of
                                                                                                             admitted/non-admitted pathways
                                                                                                             complete within 18 weeks higher
                                                                                                             than national target


298 Cost of Winter                                3     3      9       F&P have requested financial plan Lower % occupancy less
                                                                       for winter staffing this to be    requirement on short-term bed
                                                                       complete by May 2008              compliment monthly reporting by
                                                                                                         both Director of Finance and
                                                                                                         Director of Operations
300 Cost of improved staffing levels on wards     4     2      8       F&P have requested financial plan Monthly reporting by both
                                                                       for stafffing to be complete by May Director of Finance and Director
                                                                       2008                                of Operations



301 Inability to deliver short and medium term    4     3     12       Monthly performance sessions to       On target/additional schemes in
    CIP                                                                discuss new areas of CIP.             place monthly F&P Finance
                                                                                                             Report highlighting performance
                                                                                                             and new schemes




                                                                                                                               Collated by Pat Morris Head of Governance
                                                                                                                                               7/15/2010                                                                                         9
                                                                                                                             South Warwickshire General Hospitals NHS Trust
                                                                                                                                         Assurance Framework
                                                                                                                                                                                                                                                                             Objective 4
     Principle Objective 4:                       The Trust will improve processe that support its response in the event of a major emergency

     SfBH Domain                                  Public Health

     Lead Director                                Director of Operations

     Assuring Committee                           Clinical Governance and Finance and Performance Committees



                                                    Initial Risk
                                                                                                                                                                                                                                                                               Who                    When
ID   Risks                                            Rating            Controls                          Assurances                       Positive Assurances               Gaps in Controls                 Gaps in Assurance Action Plan
                                                        MAY                                                                                Identified in Board Reports and
                                                                                                                                           External Assessments


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266 Resource constraints to complete all           3       4       12   Part-time planning lead           Corporate Affairs Committee                                        Business Continuity Training     Schedule for Assuring Major Incident Training             Emergency                     31/03/2009
    actions relating to business continuity                                                               minutes                                                                                             Committee                                                 Planning Lead
    plans, major incident testing and training.

                                                                        Business Continuity Strategy      Finance and Performance                                            Business Continuity Plans                               Business Continuity Plans to be    Emergency                     01/09/2008
                                                                                                          Committee minutes                                                                                                          developed by key departments       Planning Lead
                                                                        Major Incident Plan                                                                                  Testing of Major Incident Plan                          Major Incident Plan Test (EMERGO   Emergency                     01/09/2008
                                                                                                                                                                                                                                     Training)                          Planning Lead
                                                                        Flu Pandemic Plan                                                                                    Flu Pandemic Plan needs                                 Update Flu Pandemic Plan           Emergency                     31/12/2008
                                                                                                                                                                             updating                                                                                   Planning Lead
 24 Back-up Generator will not supply                  5       4   20   Drop out contactors - growth in    Monthly Testing of Generators                                                                                             To be discussed at Capital         Director of Facilities         5/31/2008
    electricity to specific areas of site                               demand has made existing controls                                                                                                                            Committee replacement - cost
                                                                        ineffective                                                                                                                                                  approx £400K
                                                                        Key element of the Capital schemeI Reported to Capital Committee




                                                                                                                                Collated by Pat Morris Head of Governance
                                                                                                                                                 7/15/2010                                                                                                                                       10
                                                                                                             South Warwickshire General Hospitals NHS Trust                                                                                                   Objective 5


    Principle Objective 5:                 Achieve Foundation Trust Status

    SfBH Domain                            Governance

    Lead Director                          Trust Secretary

    Assuring Committee                     Foundation Trust Steering Group



                                             Initial Risk
                                                                                                                                                                                                                                                                Who            When
    Risks                                      Rating        Controls                                 Assurances                   Positive Assurances               Gaps in Controls                Gaps in Assurance Action Plan
                                                 MAY                                                                               Identified in Board Reports and
                                                                                                                                   External Assessments
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304 Creation of a 'breakable' down side     3     4     12   Regular review of planning application
    financial case due to the loss of                        progress
    income if Circle undertake NHS work
    in addition to private work at the
    proposed Tournament Fields Hospital


                                                             Director level contact with Circle as
                                                             and when required
                                                             Clear explanation of this risk in the risk Regular scrutiny and challenge FT Steering Group Reports and Adequacy of content of whole    Scrutiny and challenge Work Commissioned from         Trust           EA Report 28
                                                             chapter of the IBP                         at FT Steering Group and TB Trust Board reports              IBP unknown                     not independent of the external audit, as part of the Secretary       May 2008
                                                                                                                                                                                                     Trust                  2008/09 Audit Plan to review
                                                                                                                                                                                                                            the content of the IBP

                                                             Rigorous testing of down side financial Regular scrutiny and challenge FT Steering Group Reports and Adequacy of content of LTFM        Scrutiny and challenge Work Commissioned from         Director of     EA Report 28
                                                             case of LTFM                            at FT Steering Group and TB Trust Board reports              unknown                            not independent of the external audit, as part of the Finance         May 2008
                                                                                                                                                                                                     Trust                  2008/09 Audit Plan to review
                                                                                                                                                                                                                            the content of the LTFM

305 Board Committee structure that does     4     2      8   Annual Review of Committee structure Reviews conducted by the         Reports to Trust Board in         More regular review may be      Potential for             Work commissioned from         Chairman/Trus EA report 2
    not provide sufficient assurances to                     by the Trust Board lead by the       Chairman in 2007 and 2008        February 2007 and 2008            required as Trust progresses to Committee structure to    external audit, as part of the t Secretary   June 2008
    the Trust Board consistent with                          Chairman                             and reported to the Trust                                          FT status                       not be consistent with    2008/09 Audit Plan to review
    Monitor's compliance framework                                                                Board                                                                                              Monitor's new             the Board Committee
                                                                                                                                                                                                     compliance framework      structure to ensure that it
                                                                                                                                                                                                     issued in May 2008,       can deliver sufficient
                                                                                                                                                                                                     given last review was     assurance to self certify
                                                                                                                                                                                                     carried out in February   against Monitor's compliance
                                                                                                                                                                                                     2008                      framework


                                                             Committees required to review their      Item on Committees annual    Committee agendas, reports
                                                             terms of reference annually and          schedule of business         and Minutes
                                                             propose any changes to the Trust
                                                             Board
306 Trust unable to obtain PCT support      4     3     12   Regular dialogue between PCT CE/DF Regular meetings scheduled
    and 'buy-in' for the IBP and LTFM                        and Trust CE/DF
                                                             Director level PCT rep on Steering Both PCT CE and DF have                                              Once activity plans and                                   Continue to engage with      Chief          For duration
                                                             Group                              attended Steering Group                                              contracts are finalized PCT                               PCT to maintain director-    Executive      of project
                                                                                                meetings                                                             representation on Steering                                level focus on FT
                                                                                                                                                                     Group may be delegated to
                                                                                                                                                                     below Director level




                                                                                                                 Collated by Pat Morris Head of Governance
                                                                                                                                 7/15/2010
                                                                                                                 South Warwickshire General Hospitals NHS Trust                                                                                                    Objective 5


                                             Initial Risk
                                                                                                                                                                                                                                                                     Who             When
    Risks                                      Rating            Controls                                 Assurances                      Positive Assurances               Gaps in Controls                Gaps in Assurance Action Plan
                                                 MAY                                                                                      Identified in Board Reports and
                                                                                                                                          External Assessments




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                                                                 PCT have received/to receive drafts of                                                                                                     Formal response       Chase up response             Trust             ###########
                                                                 IBP for comment                        Formal letter sent (May 2008)                                                                       awaited from PCT                                    Secretary
                                                                                                        by CE seeking PCT support for
                                                                                                        Trust's FT application
307 Insufficient public Members are         5       3       15   Compilation of communications and      Additional Communications                                           No full time Communications     Additional            Pursue recruitment of full  Trust               Aug 2008/
    recruited to satisfy Monitor's                               consultation plan to ensure            support pursuing plan                                               Officer                         communications        time Communications Officer Secretary           Sept 2008
    requirements                                                 opportunities for membership                                                                                                               support temporary and
                                                                 recruitment maximized                                                                                                                      part time
                                                                 Target set for staff to each recruit 2   Receipt of Membership                                             No dedicated membership                               Pursue business case for   Trust                Aug 2008
                                                                 public members                           application forms                                                 resource                                              both Membership            Secretary
                                                                                                                                                                                                                                  recruitment and Membership
                                                                                                                                                                                                                                  Management resource

                                                                 Development of Membership Strategy Outline Strategy part of IBP2

                                                                 Patients targeted through letter    Receipt of Membership                                                  No dedicated membership                               Pursue business case for      Trust             Aug 2008
                                                                 attachment and personal approach by application forms in direct                                            resource                                              both Membership               Secretary
                                                                 volunteer in outpatients            response to these approaches                                                                                                 recruitment (phase 1 and 2)
                                                                                                                                                                                                                                  and Membership
                                                                                                                                                                                                                                  Management resource
308 Public members are not representative       5       3   15   Regular analysis of membership         Consideration by Project Team Reports to Project Team and           No dedicated membership                               Pursue external Membership Trust                Sept/Oct
    of the community served by the Trust                         database re gender, age, ethnicity and and Steering Group            Steering Group                        resource                                              recruitment resource (phase Secretary           2008
                                                                 postcode                                                                                                                                                         2)


                                                                 Targeting of minority community          Consideration by Project Team Reports to Project Team and         No full time Communications     Additional            Pursue recruitment of full  Trust               Aug 2008/
                                                                 groups in communications and             and Steering Group            Steering Group                      Officer                         communications        time Communications Officer Secretary           Sept 2008
                                                                 consultation plan                                                                                                                          support temporary and
                                                                                                                                                                                                            part time
280 Staff do not get involved in the        3       3       9    Regular FT Briefings with staff in a     Monitoring of number of staff                                     FT Newsletter                                         Develop and deliver FT        Trust               31/05/2008
    Foundation Trust application                                 variety of formats, venues and times     members                                                                                                                 Newsletter                    Secretary

                                                                 Invite key staff to participate in Public Attendance at Briefings                                          Frequently asked Questions E- Number of e-mails       Process to be developed       Trust               30/06/2008
                                                                 Briefings to enable them to feedback to                                                                    mail process                                          and implemented               Secretary
                                                                 their staff
                                                                 Joint Negotiation and Consultation        Minutes of Joint Negotiation                                     Stand in Dining room during                           Health & Safety Officer to co- Health &           30/06/2008
                                                                 Committee                                 and Consultation Committee                                       Well-being week w/c June 30th                         ordinate stand                 Safety Advisor

                                                                 Team Brief                               Featured in Pulse
                                                                 Pulse




                                                                                                                      Collated by Pat Morris Head of Governance
                                                                                                                                      7/15/2010
                                                                                                                                  South Warwickshire General Hospitals NHS Trust
                                                                                                                                              Assurance Framework
                                                                                                                                                                                                                                                                                      Objective 6
    Principle Objective 6:                        The Trust will improve staff involvement in all aspects of the organisation

    SfBH Domain                                   Governance

    Lead Director                                 Director of Human Resources

    Assuring Committee                            Corporate Affairs Committee



                                                    Initial Risk
                                                                                                                                                                                                                                                                                                Who           When
    Risks                                             Rating             Controls                                              Assurances                           Positive Assurances               Gaps in Controls                      Gaps in AssuranceAction Plan
                                                        MAY                                                                                                         Identified in Board Reports and
                                                                                                                                                                    External Assessments


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279 Staff do not receive an annual appraisal       3       3      9      Cascade of an objective to achieve appraisal for      Feedback route through the
                                                                         all staff                                             management structure
                                                                         Role identified and recruited to support delvery of   Quarterly monitoring in HR
                                                                         apraisal and KSF at department level                  outcome reported to Corporate
                                                                                                                               Affairs Committee
                                                                         Reviewed and simplified KSF and Appraisal             National Staff Survey
                                                                         paperwork
                                                                         Ongoing Reviewer and Reviewing Training                Investors in People re-
                                                                                                                                accreditation late autumn
280 Staff do not get involved in the Foundation    3       3      9      Regular FT Briefings with staff in a variety of        Monitring of number of staff                                          FT Newsletter                                          Devlop and deliver FT       Trust Secretary      31/05/2008
    Trust application                                                    formats, venues and times                              members                                                                                                                      Newsletter
                                                                         Invite key staff to participate in Public Briefings to Attendance at Briefings                                               Frequently asked Questions E-mail Number of e-mails    Process to be developed and Trust Secretary      30/06/2008
                                                                         enable them to feedback to their staff                                                                                       process                                                implemented

                                                                         Joint Negotiation and Consultation Committee          Minutes of Joint Negotiation and                                       Stand in Dining room during Well-                      Health & Safety Officer to co- Health & Safety   30/06/2008
                                                                                                                               Consultation Committee                                                 being week w/c June 30th                               ordinate stand                 Advisor

                                                                         Team Brief                                            Featured in Pulse
                                                                         Pulse
281 Managers do not engage in the pilot and        4       3      12     Pilot in Therapies, IT and HR                         The ability to report training and                                     Newsletter                                             Develop and deliver           Director of HR     31/10/2008
    roll-out of Electronic Staff Record                                                                                        appraisal through ESR                                                                                                         Newsletter
    Manager Self-Serve
                                                                         Training of Managers in pilot areas in preparation Six monthly report to Corporate                                           Manager Briefings                                      Programme of briefing to be Director of HR       31/03/2009
                                                                         of implementation                                  Affairs Committee                                                                                                                developed and implemented

                                                                         HR has populated Oracle Learning Management           Monitoring by Learning group                                           Training of all Managers in                            Programme of Training to be Director of HR       31/03/2009
                                                                         for all areas                                                                                                                preparation for roll-out across the                    developed and implemented
                                                                                                                                                                                                      Trust in 09/10
                                                                                                                                                                                                      Software incompatible with PAS                         Implement solution            Associate          31/03/2009
                                                                                                                                                                                                                                                                                           Director for IT




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                                                                                                                       South Warwickshire General Hospitals NHS Trust
                                                                                                                                   Assurance Framework
                                                                                                                                                                                                                                                                         Objective 6
                                                  Initial Risk
                                                                                                                                                                                                                                                                                  Who          When
   Risks                                            Rating          Controls                                        Assurances                            Positive Assurances               Gaps in Controls                Gaps in AssuranceAction Plan
                                                      MAY                                                                                                 Identified in Board Reports and
                                                                                                                                                          External Assessments




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36 Staff suffer from work related stress which    5      3   15     Training incorporated into Managers H & S       Abcence and turnover levels                                             Well being week w/c June 30th                    Staff stress survey to be       Health & Safety   31/03/2009
   may lead to higher absenteeism, risk of                          training.                                       monitored through the Finance &                                         2008                                             repeated in 2008-9.             Officer
   permanent health damage to staff,                                                                                Performance and Trust Board.
   retention issues, litigation from staff, low
   morale

                                                                    Training pathway implemented for healthcare     High level incident report reported                                                                                      More staff to be recruited to   Head of Nursing     Ongoing
                                                                    assistants.                                     to Corporate Affairs Committee .                                                                                         Maternity Service following     & Midwifery
                                                                                                                                                                                                                                             agreement at Trust Board.

                                                                    Equality & Diversity training.                  RE-audit of Well-being survey in                                                                                         Staffing levels on ward to be Head of Nursing     30/06/2008
                                                                                                                    January 2009.                                                                                                            assessed.                     & Midwifery

                                                                    Zero tolerance to bullying and harassment.      National Staff Survey October
                                                                                                                    2008
                                                                    Creation of group for implementing HSE          Featured in Pulse
                                                                    Management Standards for work related stress.

                                                                    Access for staff to Professional counselling.

                                                                    Well being page on Intranet




                                                                                                                           Collated by Pat Morris Head of Governance
                                                                                                                                           7/15/2010                                                                                                                                     14
                                                                                                                     South Warwickshire General Hospitals NHS Trust
                                                                                                                                 Assurance Framework
                                                                                                                                                                                                                                                                         Objective 7
    Principle Objective 7:                    The Trust will develop and implement new technology to improve efficiency and patient care

    SfBH Domain                               Patient Focus, Clinical Cost & Effectiveness

    Lead Director                             Director of Development

    Assuring Committee                        Finance & Performance Committee



                                                Initial Risk
                                                                                                                                                                                                                                                                             Who                When
    Risks                                         Rating            Controls                            Assurances                            Positive Assurances               Gaps in Controls                   Gaps in Assurance Action Plan
                                                    MAY                                                                                       Identified in Board Reports and
                                                                                                                                              External Assessments


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292 Loss of CPA accreditation for pathology    4       3       12   Project Plan to relocate Pathology Monthly Capital Committee
    services due to accomodation issues                             Services by Feb 2009

                                                                    Project Lead and Team               Bi-monthly Management Board
                                                                    Capital Plan                        Bi-monthly Finance &
                                                                                                        Performance Committee
293 Pathology analysers fail, before           5       4       20   Procurement Process underway        Monthly Pathology Network
    replacements are available, and can no                                                              Board
    longer be used
                                                                    Plan available to provide adequate Strategic Partnership Board
                                                                    accomodation for analysers

                                                                    Loan heamatology analyser             Incident reporting mechanism set-
                                                                    available from suppliers if required up with UHCW

                                                                    Additional Chemistry analyser       Extra resilience in new Path
                                                                    available in Blood Bank             Scheme
294 The Trust provides accomodation that       4       3       12   Pathology Network Plan to           Monthly Pathology Network
    does not support the future service                             determin service model for          Board
    models for pathology services                                   histopathology

                                                                    Project Team Knowledge              Strategic Partnership Board

                                                                    Flexible accomodation               Bi-monthly Management Board
295 Unable to release Cardiologists for        3       4       12   Workload Planning                                                                                           Insufficient capacity within the   Reporting mechanisms Develop a capacity plan for Director of                  6/30/2008
    training to enable development of                                                                                                                                           Cardilogy Service to release                            Cardiology to enable release Operations
    Interventional Cardiology Service                                                                                                                                           Cardilogists for training                               Cardiologists for 3 months
                                                                                                                                                                                                                                        intensive training
296 New Maternity system is not implemented        4       2   8    Project Plan with funding for       Monthly Project Board                                                                                                            Implement PAS upgrade           Head of Nursing         9/13/2008
    due to continued interface problems.                            Hardware and Training Backfill                                                                                                                                       LE2.2AB in September as         and Midwifery
                                                                                                                                                                                                                                         planned
                                                                    Seconded Project Midwife            Weekly Project Team meetings                                                                                                     Train Evolution users against   Head of Nursing        12/31/2008
                                                                                                        plus monthly Programme Office                                                                                                    this version of the software    and Midwifery
                                                                                                        Review                                                                                                                           and interface
                                                                    Experienced Programme Office,       LHC IT Programme Board
                                                                    utilising PRINCE2 Methodology




                                                                                                                         Collated by Pat Morris Head of Governance
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                                                                                                                                              South Warwickshire General Hospitals NHS Trust
                                                                                                                                                          Assurance Framework
                                                                                                                                                                                                                                                                                           Objective 7
                                                         Initial Risk
                                                                                                                                                                                                                                                                                                Who           When
     Risks                                                 Rating                     Controls                                   Assurances                           Positive Assurances               Gaps in Controls                   Gaps in Assurance Action Plan
                                                             MAY                                                                                                      Identified in Board Reports and
                                                                                                                                                                      External Assessments




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297 Unable to upgrade Radilology equipment                   4        4   16          Upgrade of some radiology                  Capital Committee                                                      Develop plan for upgrade of all                      Develop plan for upgrade of   Director of        30/06/2008
    to meet service demands due to lack of                                            equipment included in Capital                                                                                     required radiology equipment                         all required radiology        Development
    capital funding or lack of available space                                        Programme                                                                                                                                                              equipment to be presented
                                                                                                                                                                                                                                                             at February Capital
                                                                                                                                                                                                                                                             Committee

238 Transfer of Patients from Radiology Dept             3        4       12          Minimum of 2 staff to transfer             Cross-divisional Risk Group                                            Inadequate external lighting                         Facilities to cost out the     Assistant          6/30/2008
    to MRI Van located in Car Park C                                                                                             reviews incident reports                                                                                                    need to imstall level surfaces General
                                                                                                                                                                                                                                                             and lighting                   Manager -
                                                                                                                                                                                                                                                                                            Radiology
                                                                                                                                 Health & Safety Committee to                                           Uneven surfaces
                                                                                                                                 review incident reports and risk
                                                                                                                                 register
                                                                                                                                 Quarterly review at Risk                                               Patients exposed to the elements                     Patients to be screened for
                                                                                                                                 Management Board                                                                                                            suitability
239 Transfer of patients internally within MRI scanner   3        4       12          Training to use PAT slide in the Scanner   Cross-divisional Risk Group                                                                                                 Has been discussed in
                                                                                      van during update moving and handling      reviews incident reporting Health                                                                                           budget setting
                                                                                      training                                   & Safety Committee

                                                                                      Training to move patients from chairs      Health & Safety Committee to
                                                                                      during moving & handling updates           review incident reporting and risk
                                                                                                                                 register

                                                                                                                                 Quarterly review at Risk
                                                                                                                                 Management Board
 66 Manufacturers only validate tests when these are     5        3       15          Blue film has been applied to windows.     Cross-divisional Risk Group
    carried out in their specified conditions when                                    Portable coolers in use when required.     reviews incident report.
    laboratory temperatures are too high for the                                      Project Plan to relocate Pathology         Health & Safety Committee
    analysers to work properly the results cannot be                                  Services by Feb 2009 (see Risk 292)        review incident reports and Risk
    validate. The analysers have problems when the                                                                               Register.
    temperature become to high. They cut out and                                                                                 Quarterly review at Risk
    tests often have to be repeated                                                                                              Management Board




                                                                                                                                                  Collated by Pat Morris Head of Governance
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                                                                                                                         South Warwickshire General Hospitals NHS Trust
                                                                                                                                     Assurance Framework
                                                                                                                                                                                                                                                                   Objective 8
     Principle Objective 8:                         The Trust will improve local access to specialist care

     SfBH Domain                                    Patient Focus, Accessible and Responsive Care

     Lead Director                                  Director of Development

     Assuring Committee                             Corporate Affairs Committee



                                                      Initial Risk
                                                                                                                                                                                                                                                                           Who           When
     Risks                                              Rating             Controls                         Assurances                       Positive Assurances               Gaps in Controls                     Gaps in Assurance Action Plan
                                                          MAY                                                                                Identified in Board Reports and
                                                                                                                                             External Assessments


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282 Services developed at Stratford Hospital         3     3       9       Market Assessment                Corporate Affairs Committee                                        Marketing plan to include                                Marketing Plan to be written Director of         31/05/2008
    do not attract additional patient referrals                                                                                                                                schedule of meetings with specific                                                    Development
                                                                                                                                                                               GP practices and specialties

                                                                           Service Development Plans        Finance and Performance
                                                                                                            Committee
                                                                           Public and Patient Input         Community and Hospital
                                                                                                            Information Exchange Forum
                                                                                                            (CHIEF)
283 Loss of GP Out-of Hours Service and              4     3       12      PCT engagement                   Finance and Performance                                            Formalisation of process and                             Set up project structure      Director of        30/06/2008
    consequestial loss of income                                                                            Committee                                                          project plan.                                                                          Development
                                                                           Implementation of PCT
                                                                           requirements
                                                                           Service Standards consistently
                                                                           achieved
284 Unable to develop services in the                3     4      12       GP Meetings                      Corporate Affairs Committee                                        Clear plans from PCt not available
    community because of lack of support
    from PCT/GP or lack of accomodation or
    lack of resources
                                                                           PCT Plans                        Finance and Performance                                            Meeting with GPs from Alcester                           Meeting to be set-up          Director of         5/31/2008
                                                                                                            Committee                                                                                                                                                 Finance
                                                                           Service Development Plans
285 Unable to provide cost effective                 5     4      20       Developed plans and Business     Management Board                                                   Anaesthetic support for proposed                         Gain support and implement Director of           31/07/2008
    anaesthetic and surgical services out of                               case approval                                                                                       plans                                                    plan                       Operations
    hours from August 2008
286 Cancer Unit facility is not available for use    4     4      16       Project Team                     Project team and project Board
    by October 2008 to enable pathology and                                                                 meetings
    pharmacy developments

                                                                           Project Plan                     Capital Committee and
                                                                                                            Management Board
287 Oncology Patients are not repatriated to         4     3      12       Project Team and Project Board   Management Board                                                   No confirmed agreement from                              Obtain written confirmation   Director of        31/07/2008
    the Trust from other providers                                                                                                                                             UHCW re increased oncology                               of Oncology input             Development
                                                                                                                                                                               support
                                                                           Project Plan


288 Inadequate staffing limits further               4     4      16       Trust Board approval for a phased Management Board                                                  Action plan required to address                          Action plan to be completed Director of          30/06/2008
    development of maternity services                                      program of staff recruitment                                                                        concerns raised in West Midalnds                                                     Development
                                                                                                                                                                               Review of Services
                                                                           Service Development plans        FT Project team and Steering
                                                                                                            Board
                                                                                                            Budget setting

                                                    Initial Risk Rating
                                                                                                                                                                                                                                                                            Who           When
     Risks                                                                 Controls                         Assurances                       Positive Assurances               Gaps in Controls                     Gaps in Assurance   Action Plan
                                                          MAY                                                                                Identified in Board Reports and
                                                                                                                                             External Assessments




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                                                                                                                                            7/15/2010                                                                                                                               17
                                                                                                                      South Warwickshire General Hospitals NHS Trust
                                                                                                                                  Assurance Framework
                                                                                                                                                                                                                                        Objective 8




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  8 Maternity Unit is understaffed according         5       4       20   Trust Board approval for a phased Management Board                                                                             Funding according to             Head of Nursing Ongoing
    to the results of the Birthrate plus audit                            program of staff recruitment                                                                                                   phased program and               & Midwifery
                                                                                                                                                                                                         reassess based on
                                                                                                                                                                                                         recruitment
                                                                                                          FT Project team and Steering
                                                                                                          Board
                                                                                                          Budget setting
243 There is a risk of injury to staff if required   5       3       15   Ensuring other treatments are   Monitored by Cross Divisional                              No alarm/call bell in bathroom      To fit an alarm/call bell in     Manager of         7/31/2008
    to assist a patient following a collapse in                           accessed before the one that    Health & Safety Committee                                                                      bathroom                         Dermatology
    the bath in the Dermatology Unit                                      requires the bath               quarterly                                                                                                                       Unit

                                                                          Patient assessment to include   Monitored by Health & Safety                               Unable to lift patient out of the   Implementation of written        Manager of         7/31/2008
                                                                          history of fainting             Committee quarterly                                        bath                                plan to evacuate a patient       Dermatology
                                                                                                                                                                                                         from bath                        Unit
                                                                                                          Monitored by Risk Management                                                                   Staff training for evacuation    Manager of         7/31/2008
                                                                                                          Board quarterly                                                                                                                 Dermatology
                                                                                                                                                                                                                                          Unit

244 Risk of injury to staff if required to assist        5       3   15   Screening of patient prior to   Monitored by Cross Divisional                              Insufficient room to enable         To assess feasibility of         Manager of         7/31/2008
    patient who has collapsed in the PUVA                                 PUVA treatment                  Health & Safety Committee                                  assistance to be given              treatment door to open           Dermatology
    room                                                                                                  quarterly                                                                                      outwards to allow more           Unit
                                                                                                                                                                                                         space to assist patient
                                                                                                          Monitored by Health & Safety                               Alarm not available                 Alarm cord for staff to call for Manager of         7/31/2008
                                                                                                          Committee quarterly                                                                            assistance                       Dermatology
                                                                                                                                                                                                                                          Unit
                                                                                                          Monitored by Risk Management                                                                   Implement a written              Manager of         7/31/2008
                                                                                                          Board quarterly                                                                                emergency plan for               Dermatology
                                                                                                                                                                                                         evacuation of patient from       Unit
                                                                                                                                                                                                         room
                                                                                                                                                                                                         Staff training in evacuation     Manager of         7/31/2008
                                                                                                                                                                                                         plan for patient                 Dermatology
                                                                                                                                                                                                                                          Unit
                                                                                                                                                                                                         Obtain appropriate slide         Manager of         7/31/2008
                                                                                                                                                                                                         sheets to assist in patient      Dermatology
                                                                                                                                                                                                         handling                         Unit




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                                                                                                                                          7/15/2010                                                                                                     18
                                                                                                                        South Warwickshire General Hospitals NHS Trust
                                                                                                                                    Assurance Framework
                                                                                                                                                                                                                                                                           Objective 9
     Principle Objective 9:                       The Trust will improve the patient and public experience within the Trust

     SfBH Domain                                  Patient Focus, Accessible and Responsive Care, Care Environment & Amenities

     Lead Director                                Director of Development

     Assuring Committee                           Clinical Governance and Corporate Affairs Committees



                                                    Initial Risk
                                                                                                                                                                                                                                                                                Who          When
     Risks                                            Rating         Controls                           Assurances                              Positive Assurances               Gaps in Controls                    Gaps in AssuranceAction Plan
                                                        MAY                                                                                     Identified in Board Reports and
                                                                                                                                                External Assessments


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275 The Trust is unable to provide easier          4    3     12     Project team                       Monthly Capital Committee Meeting                                         Project Plan                        Agreement of Project Develop Project Plan           Director of        31/05/2008
    access to Pharmacy Services for out-                                                                                                                                                                              Plan at Captal                                      Development
    patients                                                                                                                                                                                                          Committee June 2008

                                                                     Capital Plan                       Bi-Monthly Management Board
                                                                                                        Meeting


276 Increase in car parking provides               4    4     16     Government Green Travel            Monthly Capital Committee Meeting                                         Assessment of future on-going       Agreement of future   Assessment of future on-      Director of        31/08/2008
    insufficent capacity                                             Strategy                                                                                                     requirements for car parking on-    requirements at       going requirements for car    Operations
                                                                                                                                                                                  site                                Management Board      parking on-site
                                                                                                        Bi-Monthly Management Board                                               Project Plan: Business Case                               Develop Project Plan          Director of        31/05/2008
                                                                                                        Meeting                                                                                                                                                           Development
                                                                                                        Patient Forum Programme includes                                                                                                    Business Case                 Director of        31/10/2008
                                                                                                        Green Travel Assessment to Report                                                                                                                                 Operations
                                                                                                        progress to Corporate Affairs

277 Unable to deliver, consistently, single sex    4    5     20     Bed Management Policy              Patient Experience (Matrons) Report                                       Policy inadequate and not being                           Update policy                 Director of        31/07/2008
    bays                                                                                                to Clinical Goverance and Corporate                                       consistently followed                                                                   Operations
                                                                                                        Affairs Committees
                                                                     Bed Capacity Plan                  National Patient Survey                                                   Bed capacity plan highlights                              Proposal for incresaing       Director of        30/06/2008
                                                                                                                                                                                  limited bed capacity available                            available bed capacity        Development
                                                                     Bed Managers                       Annual PEAT report
                                                                     Care close to home multi agency    Report on Snapshot Audit to
                                                                     working party                      divisional governance groups
                                                                                                        Audit of Privacy & Dignity Charter by
                                                                                                        the Patients Forum
                                                                                                        Report to Finance & Performance
278 Trust does not receive feedback in a           3    4     12     Impressions Software               Results of Surveys reported to                                            Lack of analysis and development,                         Develop a clear process for   Director of        31/12/2008
    format that can be used to improve                                                                  Corporate Affairs Committee                                               implementation and monitoring of                          managing patient feedback     Development
    services                                                                                                                                                                      action plans as a result of
                                                                                                                                                                                  feedback
                                                                     Trust Patient Satisfaction Surveys Patient Experience Report will
                                                                     e.g Breast Care                    include complaint trends and is
                                                                                                        reported to Corporate Affairs
                                                                     Complaints Feedback
                                                                     The National Patient Survey
                                                                     Community and Hospital
                                                                     Information Exchange
                                                                     Forum(CHIEF)
                                                                     Patient Forum Surveys




                                                                                                                             Collated by Pat Morris Head of Governance
                                                                                                                                             7/15/2010                                                                                                                                  19
                                                                                                               South Warwickshire General Hospitals NHS Trust
                                                                                                                           Assurance Framework
                                                                                                                                                                                                                           Objective 9
                                               Initial Risk
                                                                                                                                                                                                                             Who         When
   Risks                                         Rating          Controls                     Assurances                               Positive Assurances               Gaps in Controls   Gaps in AssuranceAction Plan
                                                   MAY                                                                                 Identified in Board Reports and
                                                                                                                                       External Assessments




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41 Patients, visitors and staff will sustain   5    3    15      Falls Risk Assessment Tool   Patient Safety Report reporting to
   injury as a result of falling on Trust                                                     Clinical Goverance will include
   property                                                                                   information of Falls

                                                                 Incident reporting           Falls Audit


                                                                 Falls monitoring equipment   Incident reporting at Divisional Audit
                                                                                              Operational Governance Groups

                                                                                              Risk Management Board Quarterly




                                                                                                                   Collated by Pat Morris Head of Governance
                                                                                                                                   7/15/2010                                                                                        20
                                                                                                                  South Warwickshire General Hospitals NHS Trust
                                                                                                                              Assurance Framework
                                                                                                                                                                                                                                               Objective 10
    Principle Objective 10:                     The Trust will improve the supporting administrative systems

    SfBH Domain                                 Patient Focus, Accessible & Responsive Care

    Lead Director                               Director of Operations

    Assuring Committee                          Corporate Affairs and Finance and Performance Committees



                                                  Initial Risk
                                                                                                                                                                                                                                                     Who               When
    Risks                                           Rating            Controls                       Assurances                        Positive Assurances               Gaps in Controls         Gaps in Assurance Action Plan
                                                      MAY                                                                              Identified in Board Reports and
                                                                                                                                       External Assessments


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267 Recruitment into new medical secretary       3     3      9       Job Descriptions               Management Board Report by
    may be delayed                                                                                   exception
                                                                      AGM Medicine & Surgery
                                                                      nominated lead
                                                                      Structure Agreed
269 Resource constraints prevent delivering      3     3      9       GM for Medicine Accountable    Monthly Management Board Report
    of the Outpatient Booking Improvement
    plan and metrics
                                                                      Improvement plan and metrics   Monthly Finance & Perfomance
                                                                                                     Committee
270 Lack of clinical engagement in developing    3     3      9                                                                                                          Project Plan             IT Board Meetings   Develop Project Plan      Associate              30/06/2008
    patient dashboard                                                                                                                                                                                                                           Director for IT
                                                                                                                                                                         Project Structure                            Implement Project Plan    Associate              31/12/2008
                                                                                                                                                                                                                                                Director IT
                                                                                                                                                                         Communication Strategy   IT Board Meetings   Develop and Implement     Associate           30/06/2008
                                                                                                                                                                                                                      communication strategy    Director for IT    and ongoing




                                                                                                                     Collated by Pat Morris Head of Governance
                                                                                                                                     7/15/2010                                                                                                                    21
                                                                                                                         South Warwickshire General Hospitals NHS Trust
                                                                                                                                     Assurance Framework
                                                                                                                                                                                                                                                                  Objective 11
    Principle Objective 11:                      The Trust will obtain a quality of service rating from the Healthcare Commission of at least 'Good' and NHSLA level 2

    SfBH Domain                                  All Domains

    Lead Director                                Director of Operations

    Assuring Committee                           All Assuring Committees



                                                   Initial Risk
                                                                                                                                                                                                                                                                       Who            When
    Risks                                            Rating            Controls                          Assurances                        Positive Assurances               Gaps in Controls                      Gaps in Assurance Action Plan
                                                       MAY                                                                                 Identified in Board Reports and
                                                                                                                                           External Assessments


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272 Insufficient standards or national targets    4     2      8       Each standard has an assigned     Quarterly reporting to Clinical
    achieved to gain Good rating.                                      accountable senior manager.       Governace Committee.

                                                                       Programme of assurance for each Performance Matrix to F&P.
                                                                       standard to be reviewed by an
                                                                       assurance committee at least
                                                                       once during the year
                                                                                                         Included in the Internal audit
                                                                                                         programme
273 External assessment of evidence for the       4     3     12       Each criterion has been           Monthly reporting to Clinical
    NHSLA Standards may not concur with                                nominated a lead                  Governace Committee.
    own internal assessment at level 2.

                                                                       Some overlap with the SfBH
                                                                       programme of assurance for each
                                                                       standard thus evidence for the
                                                                       NHSLA will be reviewed (where
                                                                       applicable) by the same
                                                                       assurance committee at least
                                                                       once during the year


274 Not achieving level 3 Auditors Local          3     5     15                                         Monthly reporting to Clinical                                       Evidence provided for ALE                               Monitoring of processes to   Standards Co-   11/11 & 12/11
    Evaluation (ALE) Key Line of Enquiry 4.1                                                             Governace Committee.                                                insufficient to achieve level 2 for                     ensure procedures and        ordinator       2008
    (Risk Management) may result in failing 3                                                                                                                                criterion 3, 4, 5 of the NHSLA                          processes are followed for
    criterion out of 10 in Standard 1 of the                                                                                                                                 Standards                                               08/09
    NHSLA Risk Management Standards
    (7/10 required to pass standard).


                                                                                                                                                                                                                                     Possibility of an interim    Director of     11/11 & 12/11
                                                                                                                                                                                                                                     assessment by ALE before     Finance         2008
                                                                                                                                                                                                                                     November NHSLA
                                                                                                                                                                                                                                     Assessment
                                                                                                                                                                                                                                     Scrutinise and monitor       Standards Co-   11/11 & 12/11
                                                                                                                                                                                                                                     evidence being provided      ordinator       2008
                                                                                                                                                                                                                                     against the NHSLA
                                                                                                                                                                                                                                     Standards




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