Templates for Business Continuity Plan

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					                                                                                                                                                                                                                                                   COMMISSIONER ASSURANCE FRAMEWORK




                                                                                              2006/07 AF/RR
                                                                      Commissioner
Business Unit




                                                      Lead Director




                                                                                                                Risk Number




                                                                                                                                                                                                                                                                                          Traffic Light
                                                                                                                                                                                                                                                            Risk Rating




                                                                                                                                                                                                                                                                                                                                                                     Risk Rating
  Objective
  Number
                                                                                     Mapped                                                                                                                                                                                                                                                                                        Residual Risk     Assurance - External                                                                    Gaps in
                 DIRECTORATE OBJECTIVE                                                                                                             RISK                                                  Existing Controls                                                Risk Rating                                        Planned Controls                                                                                     Internal Management Assurance         Gaps In Control
                                                                                     to HCS                                                                                                                                                                                                                                                                                           Rating          (inc Internal Audit)                                                                  Assurance



   C1           Address Health inequalities;          SW               Y                                       C1.1           PCT will not close inequalities gap.            - Health equity audit                                                         16              #REF!       #REF! - Further develop and maintain links with Public Health.               12               #REF!        - HCS C18, C23, C22a, C22c   - HCS C22b                             No                 Yes - Work is
                                                                                      C18                                                                                                                                                                                                                                                                                                                                                                                                 ongoing against
                ensuring future plans have                                                                    (COM)                                                           - month review against all targets and trajectories                                                             - Ensure utilisation of health equity audit.
                                                                                      C22                                                                                                                                                                                                                                                                                                                                                                                                 the action plan -
                measures to address health                                                                                                                                    - Overarching 'Dying too young' inequalities action plan
                                                                                      C23                                                                                                                                                                                                                                                                                                                                                                                                 Dying too young
                inequalities.                                                                                                                                                 - Develop joint Needs Assessment.
                                                                                     D11C


 PQ 10 Develop and test emergency                     SB               Y                                      PQ 10.1 Failure of local NHS services to respond to a - Barnsley PCT Emergency Planning Group                                                 15              #REF!       #REF!              - Review the Care Services business continuity plan       10               #REF!         - District Audit Review      - HCS C24                             No                 No
       plans across NHS organisations                                                                         (COM) emergency situation                             - Provider Emergency Planning Group & Annual Action Plan                                                                              - Test the Care Services business continuity plan                                        2007                         - May 07 testing of 'on call system"
       in Barnsley. To comply with the                                                                                                                              - BPCT Corporate Resilience Plan                                                                                                      - Roll out the business continuity plan training for the                                                              - Sept 07 live multi-agency exercise
       Healthcare Commission                                                                                                                                        - Outbreak Plan. Incident Plan, Deliberate Biological & Radioactive                                                                   PCTs Care Services                                                                                                    operation PAMBO
       requirements and the Civil                                                                                                                                   Agents, Mass Vaccination Plan, Flu Pandemic Plan, Business                                                                            - Test Mass Treatment Plan
       Contingencies Act                                                                                                                                            Continuity Plan                                                                                                                       - Develop evacuation plans for PCT Care Services
                                                                                                                                                                    - Estates Emergency Plans                                                                                                             sites
                                                                                                                                                                    - Business Analysis & Continuity Plan templates                                                                                       - Update the Emergency Incident Escalation Plan
                                                                                                                                                                    - Mass Treatment Group                                                                                                                - Contribute to the development of an exercise test
                                                                                                                                                                    - Scenario Risk Assessment                                                                                                            programme including table top and live
                                                                                                                                                                    - Control of Infection Major Outbreak Plan                                                                                            - Ensure Care Services Emergency
                                                                                                                                                                    - All Care Services completed business impact analysis & continuity                                                                   Arrangements/Plans fit into PCT wide plans and
                                                                                                                                                                    plan templates. Prioritised programme of development underway                                                                         maintain continued representation of the Directorate at
                                                                                                                                                                    - Practice Group addressing emergency planning/business continuity in                                                                 the PCT wide group"
                                                                                                                                                                    general practice
                                                                                                                                                                    - Provider arm's business continuity plan
                                                                                                                                                                    - Communicated Heat wave Plan to Service Managers and GP
                                                                                                                                                                    practices




  PQ 1 Develop performance management                 SB               Y                                      PQ 1.1          - Failure to achieve performance targets        - Weekly monitoring of waiting times - STEIS report                           12              #REF!       #REF! - Further develop performance monitoring systems to                          8          #REF!        - Annual health Check        - Quarterly reports on annual health   No                 No
                systems and processes for the PCT                                                             (COM)                                                           - Waiting list trigger protocol                                                                                 monitor the annual health check targets                                                              including ALE                check to PCT Board
                Commissioners to facilitate the                                                                                                                               - Quarterly monitoring of the annual business plan                                                              - Ensure the systems alert the PCT to any significant                                                - LA targets review          - HCS C7f
                delivery of performance targets and                                                                                                                           - Quarterly Annual Health Check report to the PCT Board, and                                                    under or over performance and ensure action plans are                                                process
                compliance with contracts                                                                                                                                     Commissioner Directors                                                                                          put in place to undertake remedial action
                                                                                                                                                                              - Monthly/Quarterly reporting of activity returns (validation & director                                        - Ensure the PCT Board continue to receive timely and
                                                                                                                                                                              sign off)                                                                                                       accurate quarterly annual health check reports
                                                                                                                                                                              - Contract Monitoring meetings between commissioner and Provider                                                - Ensure that service improvement reviews are carried
                                                                                                                                                                              - Service Improvement review meetings                                                                           out and accurate information submitted to the
                                                                                      C7a?                                                                                    - Director sign off process                                                                                     Healthcare Commission by timescale
                                                                                       C7f                                                                                    - Client Board balanced scorecards & performance sub group minutes                                              - Ensure that the PCT Board continue to receive
                                                                                                                                                                                                                                                                                              quarterly business plan performance reports
                                                                                                                                                                                                                                                                                              - Ensure the co-ordination of the quarterly monitoring of
                                                                                                                                                                                                                                                                                              the Be Healthy section of the Children’s and Young
                                                                                                                                                                                                                                                                                              Peoples Plan
                                                                                                                                                                                                                                                                                              - Ensure all target timescales in the nGMS quality and
                                                                                                                                                                                                                                                                                              outcome framework are achieved




  PQ 3 Ensure that the PCT has                        SB               Y                                      PQ 3.1          Safety of patients & clinical effectiveness is - Policy and Procedure Manuals                                                 12              #REF!       #REF! - To co-ordinate external assessment processes                               8          #REF!        - Internal audit report      - Routine monitoring of progress by CG No                 No
       effective Governance                                                                                   (COM)           compromised through failure to put in place - Central Risk management and Health & Safety teams/ Competent                                                      (healthcare standards, ALE) and collation of required                                                2006/07 ref 11 Risk          Committee
       arrangements in place to mitigate                                              C1a                                     governance arrangements                        advisors                                                                                                         evidence portfolios                                                                                  management                   - Commissioner Governance
       risk to the organisation in                                                    C1b                                                                                    Risk Management and Health & Safety training                                                                     - To support the development of governance                                                           - HCS C7a                    Committee minutes to Board
       accordance with national                                                       C7a                                                                                    PCT Risk Register/Assurance Framework                                                                            arrangements within the commissioner organisation
       guidance                                                                       C7c                                                                                    -Safety Alerts
                                                                                      C8a                                                                                    - Incident Management and reporting
                                                                                      C12                                                                                    - Provided required statutory documents and appropriate governance
                                                                                      D1                                                                                     reports, for example the assurance framework, the statement on
                                                                                      D3                                                                                     internal control and risk management annual reports
                                                                                      D4a
                                                                                      D4b


   IS5          Modernise the existing PCT            SH               Y                                       IS5.1          - Organisation unable to modernise information - Project management function within Information Systems                       12              #REF!       #REF! - Alignment of Information Service to future re-                             8          #REF!        - External Audit 2006/07   - PRINCE Project Assurance monitored No                     No
                Infrastructure with a fit for                                                                 (COM)           systems and therefore unable to meet PCT       - PCT has structured a Board Level post ensuring appropriate                                                     organisation of the organisation                                                                     ref 4 IT Disaster Recovery by Nfit Board
                Purpose Infrastructure                                                                                        requirements                                   prioritisation - Director of Information Services                                                                                                                                                                     Plan
                                                                                                                                                                             - Agreed use of capital funding through NRAC
                                                                                                                                                                             - Governance via PRINCE & PCT NPfIT Board
                                                                                                                                                                             - Approved Infrastructure Deployment Plan for 2007/08 - aligned to
                                                                                                                                                                             other Business Objectives
                                                                                                                                                                             - Approved allocation of capital funding required for second Phase of
                                                                                                                                                                             the project
                                                                                      D6                                                                                     - Tendered for additional power/network sockets contract(s)
                                                                                                                                                                             - Continual assessments of deployment plan for 2007/08 against
                                                                                                                                                                             business objectives
                                                                                                                                                                             - Implementation of IT equipment replacement programme
                                                                                                                                                                             - Implementation and monitoring of additional power and networking
                                                                                                                                                                             based on site specific requirements against plan




   IS1          Planning and Implementation of        SH               Y                                       IS1.1          - Organisation unable to modernise information - Project management function within Information Systems                       12              #REF!       #REF! - 2007/08 Npfit implementation programme                                     8          #REF!        - ICES (Homeloans)        - Replaced Finance System (ledgers)       No                 No
                improvement to the day to day                                                                 (COM)           systems and therefore unable to meet           - PCT has structured a Board Level post ensuring appropriate                                                                                                                                                          - Choose & Book           replaced HR/Payroll System
                support for PCT information                                                                                   commissioner service specifications            prioritisation - Director of Information Services                                                                                                                                                                     - Connecting for Health
                systems                                                                                                                                                      - Agreed use of capital funding through NRAC                                                                                                                                                                          (CFH)
                                                                                                                                                                             - Governance via PRINCE & PCT NPfIT Board                                                                                                                                                                             - Care Records Service in
                                                                                                                                                                             - Implemented an IT SLA management framework                                                                                                                                                                          Mental Health
                                                                                                                                                                             - Implemented the information services work programme procedure                                                                                                                                                       - ESR
                                                                                      C13c                                                                                   - Strategy developed for linking staff on BMBC sites to PCT network -
                                                                                       D6                                                                                    Agreed 01/11/07
                                                                                                                                                                             - Implemented updated Business Continuity Procedure




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                                                                                                                                                                                                              COMMISSIONER ASSURANCE FRAMEWORK

P2    Support the delivery of quality      MK   Y                P2.1    - Risk of compromised patient safety leading to - Existing Clinical Governance arrangements with :                                            12       #REF!          #REF! - Review current clinical supervision practice and make      8    #REF!   HCS - C07a, C07c              - Board approval of new arrangements No                     No
      services that meet national and                           (COM)    a Risk of potential litigation and complaints      - Clinical Governance lead                                                                                               recommendations to achieve minimum standards
                                                                                                                               - Clinical Governance Sub Committee and other Committee structures reporting to
      local priorities, ensuring targets                                                                                     it
      are achieved.                                                                                                          - Reconfigured Governance arrangement in PCT
                                                                                                                             - Led the work on developing robust structure for integrated Clinical Governance/
                                                                                                                             Clinical with the provider arm of the PCT.
                                                                                                                             - developed a managed approach - timeline to implement the new arrangement
                                                                                                                             - Reviewed progress of revised arrangements.
                                                                                                                             - Ensured effective risk management and control measures are in place within all of
                                                                                                                             the business units.
                                                                                                                             - Reviewed the clinical governance structure and make recommendations for
                                                      C7a                                                                    change.
                                                      C7c                                                                    - Provided strong clinical leadership and clinical engagement to all of the business
                                                                                                                             units.
                                                                                                                             - Participated in the annual audit cycle in order to monitor standard/provision of care
                                                                                                                             - Reviewed and update raising the standards document PCT record keeping
                                                                                                                             standards.
                                                                                                                             - Led the role out of the essence of care benchmarking topics across all business
                                                                                                                             units.
                                                                                                                             - Developed infrastructure to support the Controlled Drugs Accountable officer role
                                                                                                                             - Continue to monitor progress by infection control team against work programme
                                                                                                                             and
                                                                                                                             associated action plans.

P1    Support the development of the       MK   Y                P1.1    - Inappropriate professional practice which         - Professional Accountability arrangements                                                12       #REF!          #REF!                                                              8    #REF!   HCS - C01a, C07a, C07c        Professional Forum report to providers No                   No
      new Business Units to enable                              (COM)    could lead to compromised Patient care              - Professional codes of conduct/practice                                                                                                                                                                                        & commissioners Governance
      them to operate as a stand alone                                                                                       - Directorate development programme produced with Lead                                                                                                                                                                          Committee
      Business                                                                                                               professionals & key managers                                                                                                                                                                                                    - PEC
                                                                                                                             - Reviewed Lead professional roles with Lead professionals & Line                                                                                                                                                               - HCS C5b, C10b
                                                                                                                             Managers reviewed
                                                                                                                             - Agreed & implemented working together principles with both Lead
                                                                                                                             professionals & Line managers
                                                                                                                             - Reviewed progress of Directorate development programme (at end of
                                                     C5a                                                                     year)
                                                     C5b                                                                     -Reviewed the lead professional roles and develop a strong
                                                     C5c                                                                     professional lead to ensure effective clinical engagement within all of
                                                     C8a                                                                     the business units
                                                     C10b                                                                    -Provided clinical support to business unit managers as they explore
                                                     C11                                                                     business opportunities and organisational growth
                                                     D4c                                                                     -Performance managed the Infection control team to ensure the Health
                                                                                                                             Act requirements are met
                                                                                                                             - Led the actioning of the CNO review in Mental Health.
                                                                                                                             - Ensured proactive involvement in key commissioning processes
                                                                                                                             - Supported the business unit in performance management of the
                                                                                                                             Safeguarding Children's Team to ensure compliance of section 11 of
                                                                                                                             Children's Act
                                                                                                                             - Supported the business units in the performance
                                                                                                                             management of the Adult Protection Teams work.

IS3   To develop the use of                SH   Y                IS3.1   - Organisation unable to modernise information - Project management function within Information Systems                                       12       #REF!          #REF!                                                              8    #REF!   - The National PRIMIS                                               No                    No
      information systems in Primary                            (COM)    systems and therefore unable to meet           - PCT has structured a Board Level post ensuring appropriate                                                                                                                                           Standard and process
      Care                                                               commissioner service specifications            prioritisation - Director of Information Services                                                                                                                                                      - External Audit report
                                                                                                                        - Agreed use of capital funding through NRAC                                                                                                                                                           2006/07 ref 4 IT Disaster
                                                                                                                        - Governance via PRINCE & PCT NPfIT Board                                                                                                                                                              Recovery
                                                                                                                        - Received IM&T DES plans from each practice                                                                                                                                                           - recommendation
                                                                                                                        - Established a monitoring process for IM&T DES                                                                                                                                                        complete and still in place
                                                                                                                        - Implemented GPSoC for GP practices                                                                                                                                                                   - GP SOC accreditation for
                                                                                                                                                                                                                                                                                                                               Primary Care Systems.




                                                      D6
                                                     C13c




HR6   To ensure the PCT meets its          GM   Y              n HR6.2   Failing to meet the requirements of the             - Fire Safety Advisor in post                                                             12       #REF!          #REF! - to agree a fire safety policy for the PCT which reflects   8    #REF!   - Fire Brigade inspections    - Fire risk assessment for each       Yes - Identification - No
      Health and Safety obligations                            / (COM)   regulatory Reform (fire Safety) Order to            - Fire Policy                                                                                                           recent changes in legislation                                             (Held by H & S                premises                              of responsible
      and priorities.                                          a         effectively, manage our fire safety                 - Reviewed Health and Safety Training within PCT                                                                        - Identify responsible Manager for each PCT premises                      department)                   - Monitoring of actions               managers at each
                                                                         arrangements                                        - Awareness of the regulatory Fire reform order to provider governance                                                  - to implement new health and safety Training                             - HSE inspections                                                   PCT premises also
                                                                                                                             committee and Health & Safety Committee                                                                                                                                                           - HCS C20a                                                          Fire Wardens,
                                                                                                                             - Joint working between Health & Safety and the Estates Department                                                                                                                                                                                                    Marshalls.
                                                     C20a,                                                                   - Reviewed Health and Safety arrangements in relation to the                                                                                                                                                                                                          - Sufficient
                                                    D12b, D1                                                                 Commissioner                                                                                                                                                                                                                                                          inspection records,
                                                                                                                                                                                                                                                                                                                                                                                                   maintenance and
                                                                                                                                                                                                                                                                                                                                                                                                   testing




Fi4   To respond to the business           SH   Y              n Fi4.3   Failure to integrate high and medium secure - Timetable of required activity agreed                                                           12       #REF!          #REF! - To relocate existing services from York and North          12   #REF!                                                                       Yes - The existing    Yes - No
      requirements       of       PCT                          / (COM)   Mental Health Commissioning Team within PCT                                                                                                                                 Yorkshire PCT to Norcom                                                                                                                       function is not yet   assurance, as
      Commissioners and Providers by                           a                                                                                                                                                                                                                                                                                                                                   operational within    function not yet
      influencing and supporting areas                                                                                                                                                                                                                                                                                                                                                             PCT                   operational
                                                      C7d
      of development                                                                                                                                                                                                                                                                                                                                                                                                     within PCT
                                                      C7f




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                                                                                                                                                                                                    COMMISSIONER ASSURANCE FRAMEWORK

PH1    To deliver health improvement        PR   Y                PH1.1    - Long term risk that Barnsley residents              - FFtF Strategy and Marketing Strategy in place                             12        #REF!          #REF! - Maintain a Risk Management framework for Fit For Future,               8    #REF!   - ScHARR Research               - Fit for the Future Steering Group 1/4ly No   No
       and reduce health inequalities                             (COM)    continue to suffer health inequalities within         - Funding Streams (LDP)                                                                                       building a culture of risk management into all aspects of the                      Project to evaluate Fit for     reports to Board
                                                                                                                                                                                                                                               programme
       through strategic leadership of                                     Barnsley and poor health compared to the rest         - Community action plans include a health focus                                                               - Lead on organization of the SY Health Inequalities Conference to
                                                                                                                                                                                                                                                                                                                                  the Future                      - Benchmarking information with other
       the Fit for the Future Programme                                    of the country                                        - Health Equity Audit                                                                                         showcase work taking place in Barnsley & to share good practice                    - Director of Public Health     areas considered at Commissioner
                                                                                                                                 - Public Health Specialists support work in each locality                                                     & new ways                                                                         STHA Performance                OMG
                                                                                                                                 - Joint Director PH BMBC/BPCT                                                                                 - Further develop Champion strategy for FftF stakeholders to                       Monitoring                      - HCS C22b
                                                                                                                                                                                                                                               ensure all sectors are fully engaged
                                                                                                                                 - Continue lobbying via SIGOMA for resources                                                                                                                                                     - HCS C23, C22a, C22c
                                                                                                                                                                                                                                               - Raise profile within 'Yorkshire Forward'
                                                                                                                                 - A financial plan to sustain The Fit for the Future (FftF) Programme                                         - Provider arm reviews equity in service provision
                                                                                                                                 - Undertake evaluation of the FftF Programme to inform future                                                 - Develop and implement action plan for Cardiovascular Disease
                                                                                                                                 development                                                                                                   to ensure all key indicators are at England average within 2 years.
                                                                                                                                 - www.barnsleyfit4thefuture.co.uk website developed                                                           - Develop the fit for future action plan 2008-2011, contributing to
                                                                                                                                                                                                                                               the Sustainable Community Strategy and the LAA 2008 -2011
                                                                                                                                 - Work programme on the wider determinants on health
                                                                                                                                                                                                                                               - Further develop the web site WWW.barnsleyfit4thefuture.co.uk,
                                                                                                                                 - Health inequality an integral part of LDP                                                                   maximising the number of visits and raising the profile of the
                                                       C22a                                                                      - Developed Action Plan for social marketing team for PCT                                                     programme
                                                                                                                                 - Health representatives on LSP delivery partnerships                                                         - Develop customer profiling/insight programme
                                                                                                                                 - Developed Health inequalities recovery plan for approval by PCT                                             - Develop Fit for the Future as a example of social marketing
                                                                                                                                 Board
                                                                                                                                 - Raise profile of health inequalities as everyone's business and ensure
                                                                                                                                 all partners know the part they need to play and each member of
                                                                                                                                 directorate staff know the part they will play
                                                                                                                                 - Complete and disseminate F4F evaluation
                                                                                                                                 - Develop programme of learning for social marketing across Fit for the
                                                                                                                                 Future partners
                                                                                                                                 - Developed Fit For Future marketing strategy for 08-2011



PH1    To deliver health improvement        PR   Y               n PH1.2   Sustainability of neighbourhood renewal               - Transferred appropriate projects to other funding streams on              12        #REF!          #REF! - To gain funding from community investment plan                         6    #REF!   - HCS C22a                      - Finance reports to Fit for the Future No     No
       and reduce health inequalities                            / (COM)   funding in to fit for the future programmes           temporary or permanent basis.                                                                              - Raise issue with PCT/LA Executive Directors and One                                                                 Steering Group
       through strategic leadership of                           a         uncertain after March 08                              - Developed health inequalities recovery plan for approval by PCT                                          Barnsley                                                                                                               - Risk Management Framework for Fit
       the Fit for the Future Programme                                                                                          Board                                                                                                      - Develop and Implement action plan for Cardiovascular                                                                for the Future monitored by Steering
                                                                                                                                 - Raise profile of health inequalities as everyone's business and ensure                                   Disease to ensure all key indicators are at England                                                                   Group
                                                                                                                                 all partners know the part they need to play and each member of the                                        average within 2 years
                                                                                                                                 directorate staff know the part they will play                                                             - Develop the Fit for the Future action plan 2008-2011,
                                                                                                                                 - Completed and disseminate F4F evaluation                                                                 contributing to the Sustainable Community Strategy and
                                                                                                                                 - Developed action plan for Social Marketing Team within PCT                                               LAA 2008-2011
                                                       C22a                                                                      - Developed programme of learning for social marketing across Fit for                                      - maintain a risk management framework for Fit for the
                                                                                                                                 the Future partners                                                                                        Future, building a culture of risk management into all
                                                                                                                                 - Developed Fit for the Future marketing strategy for 2008-2011                                            aspects of the programme
                                                                                                                                                                                                                                            - Further develop the web site
                                                                                                                                                                                                                                            www.barnsleyfit4future.co.uk, maximising the number of
                                                                                                                                                                                                                                            visits and raising the profile of the programme
                                                                                                                                                                                                                                            - Develop customer profiling/insight programme
                                                                                                                                                                                                                                            - Develop Fit for the Future as an example of social
                                                                                                                                                                                                                                            marketing

IS2    To     develop        information    SH   Y                 IS2.2   - The PCT breaches patient confidentiality            - Complaints, Incidents & Claims Sub Group identifies area of poor          10        #REF!          #REF! - Manage & store records in accordance with NHS IA                       10   #REF!   - Achievement of                - 1/4ly reports from Complaints,         No    No
       governance                 across                          (COM)    leading to complaints/litigation through failure to   practice & trends & ensures change occurs                                                                  Toolkit                                                                               compliance with the NHS         Incidents & Claims Sub Group to the
       Commissioning                                                       treat patient's information confidentially &          - Systems in place to deal with poor performance of individuals                                            - Confidentiality Code of Conduct                                                     Information Governance          Provider Governance Committee
                                                                           provide information on the use & disclosure of        - Staff induction programme includes data protection & information                                         - Review of medical records within the PCT underway                                   Toolkit (Records                - 1/4ly report to Board from Primary
                                                                           confidential information held about them              sharing presentation                                                                                       (including storage)                                                                   Management)                     Care Reference Committee
                                                       C13b                                                                      - Patient Information leaflet                                                                              - Implementing care record guarantee                                                  - Internal Audit report         - Information Governance Toolkit Self
                                                       C13c                                                                      - Implemented updated information governance intranet site                                                 - Review partnership Information Governance                                           06/07 Info Governance           Assessment
                                                                                                                                 - Implemented improved induction slot for Information Governance                                           arrangements                                                                          - HCS C13b, C13c
                                                                                                                                 - Implemented information governance framework
                                                                                                                                 - Completed information governance toolkit 2008


 C4    Acute Services Contract; Ensure      SW   Y                 C4.2    - Failure to include appropriate quality              - Monthly contract monitoring meetings with FT                               9        #REF!          #REF! - Ensure contract clauses are applied.                                   9    #REF!   - Annual Review of PCT by       - Commissioning Performance            No      No
       negotiations of contracts and                              (COM)    measures & monitor progress in achieving              - Monthly meeting between Director of Performance & Quality,                                                                                                                                     SHA                             Management Report to the Board
       effective ongoing monitoring.                                       quality standards through commissioning               Assistant Director of Commissioning and foundation trust Directors of                                                                                                                            - Post payment verification     - Contract reviews of Primary Care
                                                                           processes leading to lack of assurance of safe        Nursing and Medical Director                                                                                                                                                                     checks on 2 practices           Contractors to PCT Board annually
                                                                           effective practice                                    - Commissioner Governance Committee                                                                                                                                                              through QOF process             - Commissioner Governance Report to
                                                                                                                                                                                                                                                                                                                                  - System for PMS operating
                                                                                                                                                                                                                                                                                                                                                                  Commissioner Governance Committee
                                                                                                                                                                                                                                                                                                                                  satisfactorily against areas
                                                                                                                                                                                                                                                                                                                                                                  - Internal Audit Report Ref 19
                                                                                                                                                                                                                                                                                                                                  tested
                                                       C7d                                                                                                                                                                                                                                                                                                        Healthcare Commissioning Monthly
                                                                                                                                                                                                                                                                                                                                  - Recommendation annual
                                                                                                                                                                                                                                                                                                                                  summary of performance for      Contract Monitoring information to the
                                                                                                                                                                                                                                                                                                                                  each PMS practice to be         Board
                                                                                                                                                                                                                                                                                                                                  submitted to Board
                                                                                                                                                                                                                                                                                                                                  - Internal audit report 06/07
                                                                                                                                                                                                                                                                                                                                  ref 19 Healthcare provision &
                                                                                                                                                                                                                                                                                                                                  action plan
                                                                                                                                                                                                                                                                                                                                  - Better Care Better Value
                                                                                                                                                                                                                                                                                                                                  Metrics
PQ 5 Clinical Audit.                        SB   Y                PQ 5.1   - PCT fails to commission effective services          Clinical Audit:                                                              9        #REF!          #REF! - Bring Clinical Audit Function in house                                 9    #REF!   - Audit reports to              - Claude database of audit undertaken No       No
                                                                  (COM)    through evaluation and audit                          - Service Level Agreement for Clinical Audit                                                               - To develop a Clinical Audit Strategy                                                Governance Committee            - Monitor research (1-10 audited to
       To improve patient care and                                                                                               - Discussion at care groups                                                                                - Develop a Clinical Audit Policy.                                                                                    ensure criteria is met)
       outcomes through systematic                                                                                               - Topic identification tool                                                                                                                                                                                                      - Reports on Commissioner Clinical
       review of care against explicit                                                                                                                                                                                                                                                                                                                            Audit Schedule to Commissioner
       criteria and the implementation of                                                                                        Evaluation/Research                                                                                                                                                                                                              Governance Committee
       change.                                                                                                                   - Research Governance Sub Group - revise research proposals
                                                                                                                                 - Research Alliance
                                                                                                                                 - LREC

                                                                                                                                 - A Clinical Audit Schedule with agreed timescales is in place
                                                       C1a                                                                       - Reviewed Clinical Audit support within the PCT, in relation to
                                                       C5b                                                                       commissioned services.
                                                     C14a, b &                                                                   - Reviewed and develop Clinical Audit Training and guidance for
                                                        c                                                                        commissioned services.
                                                       D4b                                                                       - Ensured a robust Clinical Audit Schedule with agreed timescales
                                                                                                                                 - Ensured there are systems in place for monitoring the delivery of the
                                                                                                                                 Audit schedule and ensuring that action plans are implemented
                                                                                                                                 - To oversee the development of Trust-wide Audits.
                                                                                                                                 - Implemented an effective storage system of relevant electronic and
                                                                                                                                 paper documents To fulfil the requirements for retention of information
                                                                                                                                 for the Freedom of information Act and Data Protection Act
                                                                                                                                 - Developed a reporting database for all Audit projects and produce an
                                                                                                                                 annual Clinical Audit Report.




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                                                                                                                                                                                              COMMISSIONER ASSURANCE FRAMEWORK

PQ 6 Develop a systematic PCT wide          SB   Y          PQ 6.3   - Patients fail to access relevant services or fail   - Patient prospectus                                                         9        #REF!          #REF! - Review the policy for the Production of Patient         9   #REF!   - NHSLA Risk                   - Quarterly report to Board             No    No
     approach to PPI/Patient                                (COM)    to understand care & treatment through PCT            - Policy for the production of patient information                                                         Information                                                           Management Standard            - HCS C17
     Experience and implement within                                 failure to provide suitable & accessible              - Reviewing leaflets & standardise following national guidance - PPI                                       - Continue to review leaflets against the patient                     Level 1B Clinical Care &
     Commissioned Services to                                        information on services provided                      Information Sub Group                                                                                      information Guidance                                                  Competence Criteria
     ensure compliance with the                                                                                            - Patient Directory/leaflets to be produced for Choice                                                     - Support the work to produce the PCT's statutory                     - HCS C16
     Health and Social Care Act, 2001                                                                                      - Produced the PCT's Annual Report (statutory requirements) in line                                        patient publication the Patient Prospectus
                                                                                                                           with national guidance and through consultation with key stakeholders




                                                     C16
                                                     C17
                                                      D8
                                                     D11a




 C5    Develop relationship with BHNFT      SW   Y           C5.1    Shift of delivery from Secondary to Primary           - Contract Reviews                                                           9        #REF!          #REF!                                                           6   #REF!   - Better Care Better Value - Monthly contract monitoring               No    No
                                                            (COM)    Care not achieved                                     - Commissioning intensions document agreed with action plan                                                                                                                      Metrics                    information to the Board -
                                                     D5ab                                                                  - Robust demand management of the contract                                                                                                                                       - Monthly monitoring       Commissioning Performance Report
                                                     D11c                                                                   Further developed commissioning intentions                                                                                                                                      reports from SHA

PQ 9 Ensure equality and diversity is       SB   Y          PQ 9.1   Non compliance with legislative requirements in - Director lead for Equality                                                       9        #REF!          #REF! - Ensure that the PCT meets it legal requirements in      6   #REF!    - HCS C7e, C18                - Equality indicator report to Diversity No   No
     part of the PCT’s core business                        (COM)    relation to equality and diversity ensuring it is - Diversity Steering Group                                                                                     terms of equality and diversity and the general duty                  - Disability 2 tick symbol -   Steering Group
     across all its functions/activities.                            part of the PCTs core business                    - Programme of work and action plan                                                                            through the monitoring of the action plans for Race,                  positive about disabled        - Diversity Statement In PCT Annual
                                                                                                                       - Produced a job description and person specification for a PCT wide                                           Disability and Gender Equality                                        people                         Report
                                                     C5a                                                               Equality and Diversity Advisor                                                                                 - Ensure compliance with internal and external                                                       - Equality and Diversity Steering Group
                                                     C7e                                                               - Submitted job description and person specification for banding to the                                        assessment processes                                                                                 minutes to the Board
                                                     C11a                                                              Agenda for Change Office                                                                                       - Ensure that contracts and service level agreements                                                 - HCS C14b
                                                     C13a                                                              - Produced a business case and submit to the LDP process to secure                                             cover equality and diversity issues
                                                     C14a                                                              funding (short term funding for 2 years) for the Equality and Diversity                                        - Work towards developing a Single Equality Scheme
                                                     C15a                                                              Advisor post
                                                     C16                                                                Reconfigured the PCT’s Diversity Group at a strategic level to develop
                                                     C17                                                               and lead the equality and diversity work across the organisation
                                                     C18                                                               - Revised the terms of reference/membership for the PCT’s Diversity
                                                     C23                                                               Group




 E1    Ensure that the Commissioner         NM   Y           E1.1    - Unplanned (but essential) developments              - Accommodation Policy                                                       9        #REF!          #REF! - Consultation with Staff Side/SHA & other key            6   #REF!   - NHS Estates approval of      - Acute MH Project board                No    No
       arm of the PCT has a robust                          (COM)    leading to additional financial commitment and        - PCT Estates Strategy 2006                                                                                stakeholders                                                          signed off designs
       Estates Strategy to meet their                                poor environment/accommodation design                 - Strategic Service Development Plan (SSDP) 5 Year plan                                                    - Implement strategy in line with in-year developments                - Mental Health Act
       requirements                                                  leading to poor Patient experience                    - Post project evaluations on all projects                                                                 - Update of SSDP due                                                  commission visits
                                                                                                                           - Standard Financial Instructions                                                                          - Site Development Plan for Mount Vernon                              - PEAT Inspections
                                                                                                                           - Project Management Guidance document                                                                     - Business Unit Development Plans (Business Plans)                    - Kings Fund visit -
                                                     C20a                                                                  - Design to comply with Health Technical Memorandums                                                       - Review current Estates strategy in line with agreed                 Enhancing the healing
                                                     C20b                                                                  - (HTMs) & Health Building Notes (HBNs)                                                                    business plan                                                         environment scheme
                                                     C21                                                                   - Clinical involvement in design                                                                           - Propose revised strategy to service Reprovision                     - HCS C20a, C21
                                                     D12a                                                                  - Health & Safety Executive involvements at design stage                                                   Board and Commissioning OMG
                                                     D12b                                                                  - Design reviews with Key Stakeholder re SHA & DOH.                                                        - Implement accommodation register on all PCT
                                                                                                                                                                                                                                      premises
                                                                                                                                                                                                                                      - Produce Business unit occupation reports




PQ 4 Facilitate improvements in the         SB   Y          PQ 4.1   - Absence of robust structures for initiating &       - NICE Commissioner Group                                                    9        #REF!          #REF! - Develop Systems for NICE from a commissioner            9   #REF!   - Health Care Standard         - HCS C3                                No    No
     quality of care and services                           (COM)    monitoring implementation of NICE guidance            - NICE Database to track progress                                                                          perspective                                                           C5a, D2a
                                                                     resulting in failure to adopt evidence based          - Agreed systematic system for implementation                                                              - Review and develop quality frameworks Optometrists
                                                                     practice & failure to meet statutory                  - Registered Stakeholder                                                                                   and GP's
                                                                     requirements in Commissioned Services                 - Horizon scanning                                                                                         - Monitor and report on achievement towards the quality
                                                                                                                           - NICE assessment & action planning process                                                                framework for Optometrists.
                                                                                                                           - Commissioner NICE Policy                                                                                 - To monitor quality standards via review visits and
                                                                                                                           - Reviewed and developed quality frameworks for Dentists,                                                  quality tools.
                                                                                                                           Pharmacists and GP's.
                                                                                                                           - Monitored and reported on achievement towards the quality
                                                                                                                           framework for Dentists, Pharmacists and GP's
                                                                                                                           - Developed systems for quality to collate record and report information.
                                                     C3
                                                                                                                           Ensuring it feeds into the contract monitoring process of commissioned
                                                     C5a
                                                                                                                           services.
                                                     D4b
                                                                                                                           - Reviewed the requirement to develop Quality Frameworks for other
                                                                                                                           services commissioned by the PCT (other than independent
                                                                                                                           contractors).
                                                                                                                           - In line with National and Local Guidance negotiated and agreed
                                                                                                                           quality standards between the PCT and its independent contractors
                                                                                                                           and commissioned services.




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                                                                                                                                                                                                   COMMISSIONER ASSURANCE FRAMEWORK

PH8   Health     protection   through      PR   Y            PH8.1    - PCT unprepared to respond to major incidents - SYSHA Major Incident & Communication Plan (i)                                         9        #REF!          #REF! - Programme of training on & testing of major incident   9   #REF!   - Fit for Purpose review      - Table Top Emergency Planning         No   No
      effective emergency planning                           (COM)    or disease outbreaks                           - SY Health Emergency Planning Forum                                                                                  plan developed & implemented                                         and action plan               exercise PAMBO July 07
      and partnership working                                                                                        - SY Integrated Emergency Response Plan for Health Protection                                                         - Await report of outcome of training & testing                      - Additional District Audit   - LIVE exercise PAMBO planned 06
                                                                                                                     Incidents/Outbreaks                                                                                                   - Review major incident plan, flu plan, heatwave plan                assurance 2007                September 07
                                                                                                                     - Programme of testing of major incident plan with partner agencies                                                   and CBRN plans                                                                                     - HCS C24
                                                                                                                     - Public Health Business ImpactAnalysis & Continuity Plan templates                                                   - Undertake exercises in line with guidance
                                                                                                                     - PCT Major Incident Plan developed with partner agencies                                                             - Participate in South Yorkshire Emergency Planning
                                                                                                                     - Consultant in communicable disease control                                                                          Forum meetings and training
                                                                                                                     - Health Protection Nurse Specialist                                                                                  - Convene PCT Emergency Planning Group
                                                                                                                     - Major Incident Plan incorporates outbreak plan                                                                      - Respond to IPPC consultations within required
                                                                                                                     - Control of Infection Committee                                                                                      - With SYPH network re-negotiate memorandum of
                                                                                                                     - South Yorkshire Health Protection Agency                                                                            understanding with HPU
                                                    C24                                                              - Participate in South Yorkshire Emergency Planning Forum meetings &                                                  - Contribute to South Yorkshire’s on-call rota
                                                    D13c                                                             training
                                                                                                                     - PCT Emergency Planning Group
                                                                                                                     - Contribute to South Yorkshire's on-call rota
                                                                                                                     - PCT Emergency Planning Group to include representatives from
                                                                                                                     wider health community as well as BMBC
                                                                                                                     - Develop contingency planning with provider arm PCT - programme
                                                                                                                     regular simulation events in line with major incident plan
                                                                                                                     - Developed training programme in emergency planning
                                                                                                                     - Reviewed communications and set up intranet web page




IS4   Implementation of Data               SH   Y           n IS4.1   - If good quality information is not available to   - data sets received from providers are checked for data quality as part           9        #REF!          #REF! - data warehouse project                                 6   #REF!   - Data sets are not sent to                                          No   Yes - not
      warehouse within the provider                         / (COM)   the commissioner it will not be able to manage      of the process of using the information.                                                                         - data quality policy to be developed                                commissioners from                                                        enough
      and commissioner functions of                         a         providers effectively                               - Awarded contract to preferred supplier                                                                         - ALE recommendation review of data quality reports to               providers until they have                                                 independent
      the PCT to improve decision                                                                                         - Established of project team                                                                                    be undertaken by internal audit                                      been thorough data quality                                                validation of
      support and information                        C9                                                                   - Implemented activities and plans approved by the project team                                                  - Discussions with IS and PQ to work at board reports.               checks                                                                    information
      reporting.                                     D6                                                                   - Implementation of Phase 1 of Commissioner Data Warehouse                                                       Data quality                                                         - Internal report 2007/08                                                 analysis
                                                                                                                          Development                                                                                                      - Internal audit review of quality performance data                  Healthcare Provision sept                                                 processes.
                                                                                                                                                                                                                                           07/08. Involves sample testing                                       2007                                                                      Until March 08
                                                                                                                                                                                                                                                                                                                                                                                          Audit


C7    Monitoring and update the LDP,       SW   Y             C7.1    - PCT not achieving key targets, and not            - Ongoing monitoring of progress against key milestones                            9        #REF!          #REF! - Review the process for updating the LDP ensuring       6   #REF!   - SHA Support & approval - Monthly Commissioner performance          No   No
      ensuring ongoing monitoring and                        (COM)    achieving changes in service delivery                - Joint working with Finance to review & update the financial position (LDP                                     engagement of stakeholders (LDP Monitoring Group)                    of LDP                      reports to the Board
      evaluation.                                                                                                         Monitoring Group & Commissioning reports to Board)                                                                - Ensure effective outcome monitoring against plans                 - Weekly STEIS waiting list
                                                                                                                          - Completion of monthly/quarterly monitoring returns & comparison of actual
                                                                                                                                                                                                                                           - Practice Based Commissioning budgets                               reports to SHA
                                                                                                                          against planned
                                                                                                                          - Local Delivery Plan & associated structure
                                                                                                                                                                                                                                           - Expansion primary care based scheme                                - SHA Monitoring
                                                                                                                          - Good partnership arrangements                                                                                  - Implementation of community matrons & case                         - Annual Health Check
                                                                                                                          - Provider Performance Management Reporting systems                                                              management                                                           - HCS C7d - ALE
                                                                                                                          - Business Planning Framework                                                                                    - Pharmacy contracts
                                                                                                                          - Service level agreements                                                                                       - Dentist & pharmacy self assessments
                                                    C7d                                                                   - Contract Monitoring meetings                                                                                   - Clinical Governance Leads for optometry
                                                                                                                          - Secondary care Monthly Monitoring Meeting                                                                      - Ensure ongoing monitoring and progress against key
                                                                                                                          - PIA Boards                                                                                                     milestones.
                                                                                                                          - NORCOM specialist commissioning includes specialist commissioning groups &
                                                                                                                          annual work programmes
                                                                                                                          - NORCOM Annual work plans for 07/08 Long Term Strategy
                                                                                                                          - Monitoring meeting with Provider arm PCT
                                                                                                                          - GDS Contract for Dentists
                                                                                                                          - GpwSI Schemes
                                                                                                                          - Development referral pathways through Clinical Ref Group (formally managed
                                                                                                                          clinical networks)


IS1   Planning and implementation of       SH   Y             IS1.3   - Business has no process to log and manage         - Internal business planning process in Information Services                       9        #REF!          #REF! - Reporting of the programme into Provider Directors     9   #REF!                                 - Work Programme for coming IT         No   No
      improvement to the day to day                          (COM)    a programme of development items and                - Implemented an IT SLA management framework                                                                     - Implement a new helpdesk system                                                                  service. Monitored via IT SLA review
      support for PCT information                                     therefore requirements cannot be met                - Implemented the information services work programme procedure                                                  - Develop strategy for linking staff on BMBC sites to                                              meeting.
      systems                                                                                                                                                                                                                              PCT network
                                                     D6                                                                                                                                                                                    - Implement Business Continuity Procedure




P2    Support the delivery of quality      MK   Y             P2.2    - Non compliance with national & local record       - Records Management Group                                                         9        #REF!          #REF!                                                          9   #REF!   - HCS C13b, C13c, C9          - Annual Record Keeping Audit          No   No
      services that meet national and                        (COM)    keeping standards creating a potential litigation   - Clinical Governance Structures
      local priorities, ensuring targets                              risk and patients receiving inappropriate care      - The PCT's record keeping standards 'raising the standards' have been
      are achieved.                                                   due to lack of availability of records              revised and implemented into the clinical policy manual
                                                                                                                          - Trustwide Record Keeping audit is in progress to monitor implementation -
                                                                                                                          updated raising the standards document PCT record keeping standards
                                                                                                                          - Identified items arising from the Trustwide Record Keeping Audit, indicating
                                                                                                                          where improvements can be made & support where further developments
                                                                                                                          needed
                                                                                                                          - Maintained mandatory Record keeping training, reviewing content annually-
                                                                                                                          Coordinate & review record keeping in the Trust
                                                                                                                          - Provided timely reports on Record Keeping activity with the PCT
                                                     C9                                                                   - Ensured effective risk management and control measures are in place
                                                    C13b?                                                                 within all of the business units.
                                                    C13c                                                                  - Reviewed the clinical governance structure and make recommendations for
                                                                                                                          change.
                                                                                                                          - Provided strong clinical leadership and clinical engagement to all of the
                                                                                                                          business units.
                                                                                                                          - Participated in the annual audit cycle in order to monitor standard/provision
                                                                                                                          of care
                                                                                                                          - Reviewed current clinical supervision practice and make
                                                                                                                          recommendations to achieve minimum standards.
                                                                                                                          - Monitored progress by infection control team against
                                                                                                                          work programme and associated action plans.
                                                                                                                          - Developed infrastructure to support the Controlled Drugs
                                                                                                                          Accountable Officer Role

Fi2   To contribute to the effective       SH   Y             Fi2.4   -Loss of resource and reputation to the PCT          - LCFS in post                                                                    9        #REF!          #REF!                                                          9   #REF!    - Annual audit letter        - Fraud work plans                     No   No
      control of and achievement of                          (COM)    from fraud                                          - Fraud policy in place                                                                                                                                                               - Statement of Internal
      financial statutory duties                                                                                          - Workshops with senior managers                                                                                                                                                      Control
                                                                                                                          - Induction workshops                                                                                                                                                                 - Report from LCFS to
                                                                                                                          - Fraud awareness sessions with team                                                                                                                                                  Audit Committee
                                                     C7                                                                   - Fraud plan and programme of work in place                                                                                                                                           - LCFS/DoF meetings




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                                                                                                                                                                                           COMMISSIONER ASSURANCE FRAMEWORK

Fi2   To contribute to the effective   SH   Y             Fi2.5   Cash Flow Implications affected by SCG South - Strong working relationship between PCT and SCG South Finance                       9        #REF!          #REF! - Recharge info to be established before 1 April 2008       9 Low Risk     - Annual accounts audit                                              No                      No
      control of and achievement of                      (COM)    transactions                                 Staff                                                                                                                                                                                          letter from audit
      financial statutory duties                                                                               - Regular Finance Review meeting between PCT and SCG South                                                                                                                                     commission
                                                                                                               - Budget
                                                                                                               - Statements monthly
                                                                                                               - Cashflow projections agreed throughout the year




HR6   To ensure the PCT meets its      GM   Y            HR6.1    - Harm/damage occurs to                            - Trustwide & local Health & Safety Committees                                  9        #REF!          #REF! - To review existing systems & processes to ensure          6      #REF!   - Staff Survey                - H&S objectives/ performance          No                      No
      Health and Safety obligations                      (COM)    patients/staff/visitors/property failure to meet   - Health & Safety Policy & procedures                                                                         health & Safety Auditing and monitoring is robust                          - internal audit report ref   indicators monitored via the PCT H&S
      and priorities.                                             statutory requirements through failure of the      - Competent Advisors/H&S Team                                                                                 - To produce & deliver a plan to improve engagements                       06/07 11 risk management      Committee & reported to the Provider
                                                                  PCT to minimise health, safety and                 - Health & Safety/Risk Assessment Manuals                                                                     & communications between the Health & Safety Team &                        - HCS C7a, C7c, C20a          Governance Committee
                                                                  environmental risks. Non compliance with           - Health & Safety Key Objectives/Performance Indicators                                                       Operational Services
                                                                  Health & Safety regulations                        - Controls assurance risk register & action plan                                                              - Improve links with Risk Management Team
                                                                                                                     - Incident Trend monitoring                                                                                   - Review of Incident Reporting
                                                                                                                     - Mandatory training policy                                                                                   - To progress and implement the Lone Worker.
                                                                                                                     - Annual health & safety/Security report to PCT Board                                                         - To agree a Fire Safety Policy for the PCT which reflect
                                                C4 all                                                               - Implemented PCT Security Strategy & Associated action plan                                                  recent changes in legislation.
                                                 C7c                                                                 - Provided appropriate advice in respect of LIFT new builds &                                                 - To review Health and Safety Training within the PCT
                                                C20a                                                                 development of Mental Health Unit                                                                             - To implement new Health and Safety Training
                                                 D1                                                                  - Reviewed Health and Safety Training within the PCT
                                                D12a                                                                 - Reviewed health and safety arrangements in relation to the
                                                D12b                                                                 commissioner




HR1   To produce an HR Strategy        GM   Y            HR1.1    - Lack of staff engagement.                        -Annual Training Plan                                                           9        #REF!          #REF! - Raise awareness at Board level of staff capacity          9      #REF!   -Staff Survey              - Annual training plan to OMG provider    - Capacity issues   No
      which will support the                             (COM)    Organisation does not have the workforce with      - Locality Training Plan                                                                                      issues & impact on attendance                                              - IWL Practice Plus Status - Board monitors uptake staff             for staff to attend
      reconfiguration of the PCT to                               the right skills and in the right numbers to       - HR indicators                                                                                               - Work with service managers, Modernisation                                achieved 2006              development reviews                       training
      reflect the split between Care                              achieve its objectives.                            - KSF Implemented                                                                                             Directorate & staff to produce a draft strategy for                                                   - HR reports to Care Services Board       - Dimishing funding
      Services and Commissioning                                                                                     - Internal Communication Strategy                                                                             consultation covering such aspects as Leadership                                                                                                from SHA
      functions                                 C5c                                                                                                                                                                                - Discuss with Commissioner re workforce plans and
                                                C7e                                                                                                                                                                                strategies                                                                                                                                      (gaps in control not
                                                C8b                                                                                                                                                                                                                                                                                                                                considered to be
                                                C10a                                                                                                                                                                                                                                                                                                                               significant - part of
                                                C10b                                                                                                                                                                                                                                                                                                                               on-going
                                                C11a                                                                                                                                                                                                                                                                                                                               businesses
                                                C11b                                                                                                                                                                                                                                                                                                                               development)
                                                C11c
                                                D5a
                                                 D7




PH2   To reduce the prevelance of      PR   Y            PH2.1    - Failure to meet smoking cessation targets        - Smoke Free Action Plan                                                        9        #REF!          #REF! - Tobacco control scheme                                    6      #REF!   - SHA monitoring of PCT       - Reporting to OMG & Board             No                      No
      smoking in the population                          (COM)    including local LPSA2 and LAA targets              - Smoking cessation co-ordinator & dedicated team                                                             - Continue to implement the Smoke Free Barnsley                            performance                   - HCS C7f
      through tobacco control                                                                                        - Smoking cessation specialist to support primary care                                                        Action Barnsley                                                            - Data direct to DoH
      measures                                                                                                       - Re-costed recovery plan                                                                                     - Ensure LPSA2 & LAA targets are met on Tobacco                            - DoH Smoking cessation
                                                                                                                     - QOF points within NGMS contract relating to smokers with chronic diseases                                   Control                                                                    team
                                                                                                                     - Enhanced service for smoking cessation in general practice
                                                                                                                                                                                                                                   - Target patients with CHD/Diabetes for support to stop                    - Healthcare Commission
                                                                                                                     - Publicity Campaign
                                                                                                                                                                                                                                   smoking                                                                    Service Improvement
                                                                                                                     - Smoking cessation stats in Locality Clinical Networks
                                                                                                                     - Ensure LPSA2 & LAA targets are met on Tobacco Control
                                                                                                                                                                                                                                            - Support those delivering the local enhanced                     Review
                                                                                                                     - Support all Primary & Secondary schools to go Smoke Free                                                    service                                                                    - HCS C23
                                                                                                                     - Provide leadership & support to help workplaces & business go smoke free                                             - Work alongside BHNFT to target patients
                                                                                                                     - Support the PCT to implement its Tobacco Control Policy                                                     with CHD and
                                                                                                                     - Provide support to new legislation for implementation on smoke free                                                    Diabetes
                                                 C7f
                                                                                                                     workplaces & public places arising from Improvement & Protection Bill                                         - Work with partners to raise awareness of dangers and
                                                C23
                                                                                                                     - Pressure to applied to re-establish audit process to measure smoking                                        reduce the supply of illegal tobacco products
                                                D13a                                                                 prevelance
                                                                                                                     - Supported commissioning in writing a new specification for stop smoking
                                                                                                                     service that incorporates the lessons from Healthy School Stop Smoking
                                                                                                                     project
                                                                                                                     - Continue to implement Smoke Free Barnsley Marketing campaign
                                                                                                                     - With the work place advisor provided leadership and support to
                                                                                                                     help work places and business to go smoke free




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                                                                                                                                                                                               COMMISSIONER ASSURANCE FRAMEWORK

Fi4    To respond to the business         SH   Y             n Fi4.2    The PCT's reputation is effected as a result of - SCG South Management Board chaired by BPCT Chief Executive                     9        #REF!          #REF!                                                                    9   #REF!   '- Chief Exec from each    - Internal audit review of SCG         No   No
       requirements       of       PCT                       / (COM)    Commissioning Decisions made by SCG South - Minutes of SCG South Management Board go to PCT Board                                                                                                                                             PCT sits on SCG board      South/Norcom. District audit review
       Commissioners and Providers by                        a          (PCT hosts SCG South)                           - Director of SCG South employed by BPCT                                                                                                                                                                                 07/08 of future arrangements SCG
       influencing and supporting areas                                                                                 - SCG South has to comply with BPCT, SFI's, SO's, S,O,D and                                                                                                                                                              South
       of development                                                                                                   Governance arrangements




                                                    C7d
                                                    C7f




 C2    Unscheduled Care; ensure plans     SW   Y                C2.1    - Failure to manage unplanned care resulting in - Development & extension of Intermediate Care services, including               9        #REF!          #REF! - Development of patient Education re Self care,                   6   #REF!   - DHA/SHA monitoring of - Benchmarking comparing with             No   No
       progressed to address                                   (COM)    financial risk to PCT & impacting on access to Hospital In Reach team, resulted in admission avoidance                                                         communication campaign                                                         unscheduled care services BHNFT
       unscheduled care needs.                                          services                                        - PEC                                                                                                          - Development of enhanced services in relation to                              - HCS C18                 - Activity data by general practice on
                                                                                                                        - Integrated Falls Service reduced falls & emergency admissions                                                chronic disease management                                                                               unplanned admissions (plan to report
                                                                                                                        - Intermediate Care Services                                                                                   - Implementation of community matrons & case                                                             to PEC)
                                                                                                                        - Unscheduled Care Workstream                                                                                  management, with a focus on High intensity users                                                         - Reports by Locality Clinical Networks
                                                                                                                        - Development Pan for A & E diversion and reduction of admission and                                           - ISIP Process                                                                                           via minutes to PEC
                                                                                                                        bed days for COPD                                                                                              - Reduction in emergency bed days                                                                        - Regular agenda item for PEC
                                                                                                                        - Social Marketing projects for A&E and COPD                                                                   - Action plan for A&E (re: diverting people away from                                                    - Clinical Network Advisory Forum
                                                     C6                                                                 - Use of Interqual to address Emergency Admissions                                                             A&E)                                                                                                     - Monitoring of secondary care activity
                                                     C18                                                                - Progressed outcomes on Long-term conditions – Community Matrons                                              - Progress and implement A&E Action Plan.                                                                through contract monitoring
                                                     C19                                                                                                                                                                                                                                                                                        - Reporting process to Trust
                                                   D11abcd                                                                                                                                                                                                                                                                                      Board/PEC
                                                                                                                                                                                                                                                                                                                                                - Commissioner OMG
                                                                                                                                                                                                                                                                                                                                                - Unscheduled Care Board
                                                                                                                                                                                                                                                                                                                                                - ISIP/LDP Process
                                                                                                                                                                                                                                                                                                                                                - HCS C19




PQ 2    Ensure that the PCT has           SB   Y             n PQ 2.1   Inappropriate Primary Care Contractors listed     - Procedures for dealing with applications for inclusion in Primary Care       8        #REF!          #REF! - Develop and maintain processes and procedures for                4   #REF!   - NCAS advice              - Reference Committee reports to the   No   No
       effective Primary Care                                / (COM)    with the PCT and thereby able to work in the      Contractor Lists                                                                                             dealing with applications for inclusion, withdrawal and                        - Compliance with external PCT Board quarterly
       Contractor List Management                            a          NHS Primary Care.                                 - Reference Committee to deal with extraordinary applications and                                            removal from, the Primary Care Contractor Lists.                               HealthCare Standards       - HCS C10a
       arrangements in place, to comply                                                                                   address issues as part of poor individual performance                                                        - Ensure that the list management legislation is                               C11a
       with relevant NHS regulations                                                                                                                                                                                                   maintained and kept up to date
       and DH guidance                                                                                                                                                                                                                 - Develop an action plan for, and implement, any major
                                                                                                                                                                                                                                       new legislation or significant changes to existing
                                                                                                                                                                                                                                       legislation
                                                                                                                                                                                                                                       - Provide reports and advice to the Primary Care
                                                                                                                                                                                                                                       Reference Committee in relation to regulatory
                                                                                                                                                                                                                                       requirements of list management regarding specific
                                                    C10a                                                                                                                                                                               individual cases
                                                    C10b                                                                                                                                                                               - Develop a more robust process for supporting the
                                                    C11a                                                                                                                                                                               Reference Committee in dealing with cases and
                                                                                                                                                                                                                                       ensuring compliance to Primary Care Contractor lists
                                                                                                                                                                                                                                       regulations
                                                                                                                                                                                                                                       - Review the Poor Performance Procedure and develop
                                                                                                                                                                                                                                       a more robust process for supporting the Reference
                                                                                                                                                                                                                                       Committee in dealing with cases and ensuring
                                                                                                                                                                                                                                       compliance to Primary Care Contractor lists regulations
                                                                                                                                                                                                                                       - Develop a whistle blowing policy for primary care




PQ 6 Develop a systematic PCT wide        SB   Y               PQ 6.1   - PCT would not achieve its statutory duty to - PPI Steering Group and Sub Groups                                                8        #REF!          #REF! -Continue to develop the tools and processes to support            4   #REF!   - National                 - Non-Executive member involved in     No   No
     approach to PPI/Patient                                   (COM)    involve and consult with patients and the public - Links with Barnsley Participation Process                                                                      staff in undertaking PPI activities and using patient                       acknowledgement for PPI    the work if the PPI Steering Group
     Experience and implement within                                                                                      - Local award to celebrate Patient & Public Involvement innovation                                              intelligence to commission services that are responsive and                 tool kit                   - HCS C17
     Commissioned Services to                                                                                             - Local complaints Leaflet                                                                                      meet the needs of the people of Barnsley                                    - Audit Commission audit
     ensure compliance with the                                                                                           - National Patient Surveys Primary Care                                                                         - Ensure that the PCT meets all national and local targets in               of PPI 2005/06
                                                                                                                          - PPI Training for Staff                                                                                        relation to PPI/Patient Experience.
     Health and Social Care Act 2001.
                                                                                                                          - Local compact of statutory/voluntary & community sector organisations                                         - Look at establishing a Patient Experience Group with
                                                                                                                          - Developed links with PCTs PPI forum                                                                           support from PCT Commissioners
                                                                                                                          - Links with Overview & Scrutiny Committee
                                                                                                                          - PPI Newsletter
                                                                                                                          - PPI Strategy
                                                                                                                          - Communications Strategy
                                                    C16                                                                   - Consultation Protocol
                                                    C17                                                                   - SHA Stocktake in April 2006 on PALS/PPI
                                                                                                                          - Guidance for the production & procedure for approval of patient & public
                                                     D8
                                                                                                                          information
                                                    D11a
                                                                                                                          - Collection & reporting of patient compliments via Complaints Manager
                                                                                                                          - Undertaken a baseline assessment to establish the current arrangements
                                                                                                                          and gaps in relation to PPI and the use of patient intelligence
                                                                                                                          - Used the information gained from the PPI Baseline Assessment to manage
                                                                                                                          the gaps and make recommendations for change
                                                                                                                          - Established links and processes to produce the Commissioner Governance
                                                                                                                          Report in the agreed format
                                                                                                                          - Reviewed and re-launch the PCT’s PPI staff toolkit.
                                                                                                                          - Produced the PCT's Annual Report (statutory requirements) in line with
                                                                                                                          national guidance and through consultation with key stakeholders




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                                                                                                                                                                                           COMMISSIONER ASSURANCE FRAMEWORK

MD1   Develop      responsive        and KWM   Y          n MD1.1   Under performance of doctors                      - Appraisal process and job planning                                           8        #REF!          #REF! - Develop intranet pages for doctors appraisal and CPD    8   #REF!   - HCS C5c, C8b, C11a,         - Annual appraisals and job plan for all No      No
      meaningful workforce planning                       / (COM)                                                     - Review, agree and monitor mandatory training for doctors within the                                        - Develop the use of the online Multi Source feedback                 C11c                          medical staff and GPs
      within the Medical Directorate                      a                                                           PCT                                                                                                          mechanism for doctors                                                                               - HCS C10b, C11b
                                                                                                                      - Review the Study Leave Policy for doctors                                                                  - to develop an external appraisal
                                                   C5c                                                                - Ensure that doctors annual appraisals are undertaken, including a
                                                   C5d                                                                review of training and completion of PDP forms
                                                   C8b                                                                - Refine Job Planning of Consultants to facilitate a more effective use of
                                                   C10b                                                               resources
                                                   C11a                                                               - Develop continuing professional development for doctors within the
                                                   C11b                                                               PCT
                                                   C11c                                                               - Primary care tutor in post
                                                                                                                      - Developed Mentorship Scheme for GPs



OD6   Maintain and further develop        KT   Y           OD6.1    Uncoordinated service provision and            - PIA                                                                             8        #REF!          #REF! - Work in partnership with supporting business units in   8   #REF!   - CSCI Inspections            - JAG Minutes                               No   No
      partnership working to improve                       (COM)    developments if non involvement of partnership - Pooled budgets                                                                                                order to share good practice and skill development                                                  - Care Services Board
                                                                                                                                                                                                                                                                                                                                       - PCT Board
      the quality and services provided            C1               working within Operational Business Units      - Clients board structure                                                                                                                                                                                           - Client Board
      in the Operational Business Units            C3                                                              - Integrated management arrangements                                                                                                                                                                                - HCS C6
                                                   C4                                                              - Joint Commissioning
                                                   C6
                                                   C13


P4    Maintain and further develop        MK   Y          n P4.1    Failure to work in partnership will lead to        - PIA Board                                                                   8        #REF!          #REF!                                                           8   #REF!   - External audit report       - HCS C6                                    No   No
      partnership working to improve                      / (COM)   compromise patient safety and reduce quality      - Client Boards                                                                                                                                                                    06/07 ref 2 - Working
      the quality of services provided                    a         of care                                           - PIA agreements                                                                                                                                                                   together
                                                                                                                      - Care Services Board                                                                                                                                                              - CSCI com for Social
                                                                                                                      - Info Sharing protocol                                                                                                                                                            Care inspection
                                                                                                                      - CPA                                                                                                                                                                              - PIA risk matrix
                                                                                                                      - Discharge Policy
                                                                                                                      - Worked in partnership with the business units to provide professional
                                                                                                                      support and share good practice across all areas.
                                                                                                                      - Worked closely with the Director of Adult Social Services in
                                                   C6                                                                 developing partnership working in line with Every Adult Matters
                                                                                                                      - Provided strong leadership and support to the Professional staff
                                                                                                                      employed in BMBC
                                                                                                                      - Explored and develop opportunities to benchmark essence of care
                                                                                                                      topics outside of the PCT.
                                                                                                                      - Worked in partnership, develop an infrastructure to support the
                                                                                                                      Controlled Drugs Accountable Officer Role.
                                                                                                                      - Worked in partnership with the PCT business units implement the non
                                                                                                                      medical prescribing strategy across all areas.
                                                                                                                      - Proactively participated in partnership work by chairing the learning
                                                                                                                      disability board.


C7    Monitoring and update the LDP,      SW   Y            C7.3    - Failure to implement 'patient choice' booking   - Processes in place                                                           8 Medium Risk          Green     - Ensure ongoing monitoring and progress against key   8   #REF!   - SHA to monitor progress - Access, Booking, Choice Steering              No   No
      ensuring ongoing monitoring and                      (COM)    systems                                           - Access, Booking, Choice Steering Group meetings                                                               milestones.                                                        - HCS C18                 Group reports to the PCT Board
                                                   C18
      evaluation.                                                                                                     - Monitoring process in place                                                                                                                                                                                reported as part of the Commissioner
                                                   D11b
                                                                                                                      - Project Manager in post                                                                                                                                                                                    Performance Management Report
                                                   D11c
                                                                                                                                                                                                                                                                                                                                   - HCS C19
                                                   D11d


C7    Monitoring and update the LDP,      SW   Y            C7.4    - The Barnsley Population fails to receive the    - Choose & Book system in place                                                8        #REF!          #REF! - Choose & Book action plan                               8   #REF!                                 - Commission Report                         No   No
      ensuring ongoing monitoring and                      (COM)    health & related services needed through          - Choose & Book Sub Group                                                                                    - Diversity Strategy action plan                                      Commissioning                 - Fit for Future Annual Report
      evaluation.                                                   failure of the PCT to commission service based    - QOF                                                                                                        - Race Equality action plan                                           - DHA/SHA oversight of        - Fit for the Future 1/4ly reports to the
                                                   C18              on ensuring access & choice                       - Fit for Future re Work Programme                                                                           - Strategic needs analysis in development                             LDP                           Board
                                                   D11b                                                               - LDP                                                                                                        Commissioning prospectus in development                               - Healthcare Commission       - Board report Commissioning
                                                   D11c                                                               - Requirements in contracts/SLA's                                                                            - Ensure ongoing monitoring and progress against key                  - Internal Audit Report Ref   - HCS C19
                                                   D11d                                                               - NORCOM Commissioning process                                                                               milestones.                                                           19 Healthcare
                                                                                                                      - Priorities Panel process & Protocols                                                                       - Prepare for development of next phase of                            Commissioning
                                                                                                                                                                                                                                   LDP/prospectus                                                        - HCS C18

IS1   Planning and implementation of      SH   Y            IS1.2   - Organisation unable to operate as an efficient - Service Level Agreed for contracted IT support                                8        #REF!          #REF! - Refine catalogue of provided information services       4   #REF!   - External Audit report                                                   No   No
      improvement to the day to day                        (COM)    business as Information Services do not          - Monitoring & analysis of Help Desk calls (more proactive)                                                   (word, excel, etc)                                                    06/07 4 IT Disaster
      support for PCT information                                   provide an adequate service                      - Appointment of Deputy Director of IS - focus on delivery of operational                                     - Infrastructure project                                              recovery
      systems                                                                                                        work                                                                                                                                                                                - recommendations
                                                                                                                     - Implemented an IT SLA management framework                                                                                                                                        complete & Still in place,
                                                                                                                     - Implemented the information services work programme procedure                                                                                                                     internal follow-up
                                                   C13c
                                                                                                                     - Developed strategy for linking staff on BMBC sites to PCT network -
                                                    D6
                                                                                                                     Agreed 1/11/2007
                                                                                                                     - Implemented updated Business Continuity Procedure




HR4   To develop ESR in order to meet     GM   Y           HR4.1    - Inefficient and ineffective HR information      - ESR system                                                                   8        #REF!          #REF! - Identify the capacity of ESR for supporting workforce   8   #REF!   -Internal audit report ref                                                No   No
      the PCT's requirements and to                        (COM)    systems which does not support the PCT's          - HR Indicator Reports                                                                                       decisions.                                                            06/07 15 payroll esr
      produce improved information to                               business.                                         - Completed project on work structures.                                                                      - Pilot for pensions                                                  - HCS C11a
      support decision making.                                                                                        - Progressed ESR 'self service' for managers.
                                                   C7e                                                                - Ensured all ESR users receive relevant training.
                                                   C10a                                                               - Considered options for maintaining ESR training within the PCT.
                                                   C11a                                                               - Considered feasibility and options for self rostering for implementation
                                                    D6                                                                in 07/08




IS3   To develop the use of               SH   Y            IS3.2   - Primary Care Practices unable to operate as     - Service Level Agreed for contracted IT support                               8        #REF!          #REF! - Refine catalogue of provided information services       4   #REF!   - National PRIMIS          - SLA Monitoring                               No   No
      information systems in Primary                       (COM)    an efficient business as Information Services     - Monitoring & analysis of Help Desk calls (more proactive)                                                  (word, excel, etc)                                                    Standards and process
      Care                                                          do not provide an adequate service                - Appointment of Deputy Director of IS - focus on delivery of operational                                                                                                          - GP Soc accreditation for
                                                                                                                      work                                                                                                                                                                               Primary Care Systems.
                                                                                                                      - Received IM&T DES plans from each practice
                                                   D6                                                                 - Established a monitoring process for IM&T DES
                                                                                                                      - Implemented GPSoC for GP practices




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                                                                                                                                                                                                      COMMISSIONER ASSURANCE FRAMEWORK

IS3   To    develop    the  use   of      SH   Y           IS3.3   - Lack of integration of IT systems to improve     - Information systems in use                                                             8       #REF!          #REF! - New ways of working to be produced for service areas      8   #REF!   Prior to roll out:             Prior to roll out:                      Yes                  Yes
      information systems In Primary                      (COM)    information sharing & support clinical care        - Choose & Book                                                                                                       dependent on system specific projects                                   - Connecting for Health        - PCT comprehensive testing prior to    - No integration     - No audits
      Care                                                         across PCT Provider Services & GP                  - PAS                                                                                                                 - Interface/integration of systems subject to appropriate               - Expert Reference Group       roll out                                - No capability to   taken place
                                                                   Community                                          - Community system                                                                                                    functionality & requirement                                             (for design &                  - Reports to Provider Directors         integrate at present
                                                                                                                      - Ad hoc individual client specific requests to PCT services/GPs                                                      - legitimate relationship to be considered & established                specifications)                - Reports to Project Boards             without significant
                                                                                                                      (Commissioner/Provider team support this)                                                                             prior to information sharing - incorporate into project                 - Strategic Health Authority   - Approved project will be subject to   local investment
                                                                                                                      - Confidentiality policy                                                                                              plans                                                                                                  YaTH SHA Performance Monitoring
                                                                                                                      - Robust clinical practice                                                                                            - Post implementation verification process - 45 day
                                                                                                                      - Regular reports to NPFIT & PCT Boards                                                                               identification of faults
                                                                                                                      - GP Practice systems EMIS/InpS offer limited integrated with NPFIT                                                   - Project PIDs to be signed off by Board
                                                   D6                                                                 (C&B, GP to GP, Prescribing)                                                                                          - GP Practices to consider future systems migration to
                                                                                                                      - Received IM&T DES plans from each practice                                                                          NPFIT compliant GP Systems such as System One
                                                                                                                      - Established a monitoring process for IM&T DES                                                                       - 2007/08 NPfit implementation programme
                                                                                                                      - Implemented GPSoC for GP Practices
                                                                                                                      - PCT MPfit process board has been expanded to include BMBC and
                                                                                                                      BHNFT
                                                                                                                      - Care Services information systems replacement programme
                                                                                                                      - SHA accepted plan IM&T which maps out integration of systems in
                                                                                                                      Barnsley



P3    To engage representative            MK   Y           P3.1    - Poor patient experience and failure to improve - Essence of Care (EoC) benchmarking process (10 benchmarks)                               8       #REF!          #REF!                                                             4   #REF!   - Staff & Service user         - Progress monitored by Governance No                       No
      service users in service delivery                   (COM)    quality of services                              - Training provided to staff on continuous basis                                                                                                                                                Survey (2006) results          Committee
                                                                                                                      - EoC Group in service areas
      and service monitoring in order                                                                                 - EoC Action Plan 2006/07
                                                                                                                                                                                                                                                                                                                    - HCS C8a                      - 1/4ly reports from Complaints, SUI &
      to ensure equitable and                                                                                         - Complaints, SUI & Claims Sub Group identifies areas of poor practice & trends &                                                                                                                                            Claims Sub Group to the Care
      accessible service development.                                                                                 ensures change occurs                                                                                                                                                                                                        Services Board.
                                                                                                                      - Systems in place to deal with poor performance of individuals                                                                                                                                                              - Essence of Care Audit
                                                                                                                      - EoC is a regular agenda item in all Clinical Governance forums & is incorporated
                                                                                                                                                                                                                                                                                                                                                   - Minutes of Provider Governance
                                                                                                                      into all formal Clinical Governance reporting systems
                                                                                                                      - Standards/audits written for EoC for record keeping & storage                                                                                                                                                              Committee to the Care Services Board
                                                   C8a                                                                - Standards/audit circle for EoC for privacy & dignity for both service user & staff                                                                                                                                         - HCS C17, C14c
                                                   C13a                                                               - Audit programme for EoC for 2006/07
                                                                                                                      - Patient representative sits on EoC Group
                                                   C13b
                                                                                                                      - EoC feeds into PPI Forum
                                                   C20a                                                               - Standards been developed for PPI involvement
                                                   C20b                                                               - EoC website for communication & sharing best practice
                                                   C21                                                                - Record keeping training provided
                                                   D2b                                                                - EoC leaflets & posters
                                                                                                                      '- To continue to role out benchmarking topics in order if priority (2006/07 promoting
                                                   D12a                                                               health/communication & nutrition)
                                                   D12b                                                               - Explored & establish alternative ways of networking & sharing best practice within
                                                                                                                      the PCT
                                                                                                                      - Explored & develop opportunities to benchmark Essence of Care topics outside the
                                                                                                                      PCT
                                                                                                                      - EoC incorporated into business plans & job descriptions
                                                                                                                      - EoC part of the new provider clinical governance frmaework & make links to better
                                                                                                                      metrics
                                                                                                                      - All audits
                                                                                                                      - Supported the PCT in ensuring that service users are engaged in the business
                                                                                                                      unit development programme

HR5   To put in place processes to        GM   Y          HR5.1    - Organisation does not have right skills in right - HR Reports to Managers                                                                 8       #REF!          #REF! - Identify capacity of ESR to support workforce             8   #REF!    - Patient Surveys             - Patient Surveys                       No                  No
      develop responsive and                              (COM)    place for services.                                - FIMS Returns                                                                                                        planning.                                                               - Service Reviews              - Service Reviews
      meaningful workforce planning.                               Inefficient decision making.                       - Revised Board Report to incorporate Agency spend & recruitment                                                      - To work with the Quality Performance Directorate to
                                                                                                                      advertising                                                                                                           ensure that all future PCT business plans included
                                                                                                                      - Review of skill mix in service (e.g. Choose & Book in Physiotherapy)                                                identification of associated staff numbers/skills
                                                                                                                      - Agreed funding for a Workforce Planning manager post with the                                                       - To work with the PCT modernisation team to ensure
                                                                                                                      commissioner. Recruited to post.                                                                                      that all service developments include identification of
                                                                                                                                                                                                                                            associated staff numbers/skills
                                                   C11a                                                                                                                                                                                     - To establish systems & processes for evaluations
                                                   C11b                                                                                                                                                                                     overall & engaging PCT workforce demands
                                                   C11c                                                                                                                                                                                     - To establish information systems to facilitate
                                                   D5a                                                                                                                                                                                      identification of potential issues affecting workforce eg
                                                   D5b                                                                                                                                                                                      labour market intelligence;
                                                    D7                                                                                                                                                                                      retirement/recruitment/turnover hotpots;
                                                                                                                                                                                                                                            qualification/skills registers
                                                                                                                                                                                                                                            - To establish reporting systems & management
                                                                                                                                                                                                                                            processes to control costs associated with the use of
                                                                                                                                                                                                                                            agency staff
                                                                                                                                                                                                                                            - To scope resource requirements to enable the PCT to
                                                                                                                                                                                                                                            process



C6    Review    of      Commissioning     SW   Y           C6.1    - PCT commissioning will not be fit for purpose    - Staff Development Reviews                                                              6       #REF!          #REF! - Seek to improve the information & monitoring systems      6   #REF!   - Fit for Purpose and          - Updates of Fit For Future             No                  No
      arrangements                                        (COM)                                                       - Fit For Purpose development Plan                                                                                    - Review the training requirements                                      action plan                    Development Plans to OMG And the
                                                                                                                                                                                                                                            - Review the operating methods in light of nationally                                                  Board
                                                                                                                                                                                                                                            published guidance & internal reviews
                                                                                                                                                                                                                                            - Develop Commissioning review project
                                                   C7d                                                                                                                                                                                      - Develop fitness for purpose plan and ensure
                                                                                                                                                                                                                                            implementation.




HR2   To commence development of          GM   Y          HR2.1    Inefficient, ineffective HR directorate which is   - Staff Survey                                                                           6       #REF!          #REF! - Review key processes involved in order to set service     6   #REF!   - results of Healthcare        - Staff Survey                          No                  Yes - to
      the HR Directorate as a potential                   (COM)    not financially viable.                            - Informal Benchmarking                                                                                               standards                                                               Standards                      - Complaints Monitoring                                     improve
      business unit                                                                                                   - HR Board Reports (performance)                                                                                      - Undertake detailed costing work.                                      - Internal Audit report on                                                                 Benchmarking
                                                                                                                      - Identify specific functions within the business unit                                                                - Agree SLA with Commissioner                                           Payroll/HR Systems i.e.
                                                                                                                      - Identify potential 'produce lines'.                                                                                                                                                         ESR ref 2006/07 15
                                                                                                                      - Worked with Director of Service Improvement and Business
                                                                                                                      Development to market at least 1 service externally.




Fi2   To contribute to the effective      SH   Y           Fi2.2   Fraudulent use of NHS resources/corruptive         - Anti Fraud Policy                                                                      6       #REF!          #REF! - To produce robust forecasts on income and                 6   #REF!   - Internal Audit/Counter    - Audit Committee                         No                   No
      control of and achievement of                       (COM)    decision making arising from failure to promote    - Code of Conduct on openness & Accountability                                                                        expenditure on a monthly basis                                          Fraud & Security reports    - Local counter fraud specialist internal
      financial statutory duties                                   openness, honesty, probity, accountability &       - Standing Order                                                                                                      - To investigate value for money opportunities through                  to Audit Committee          work programme
                                                                   economic, efficient & effective use of             - Scheme of Delegation                                                                                                its commercial procurement strategies                                   - ALE - HCS C7d
                                                                   resources.                                         - Hospitality Policy                                                                                                                                                                          - Various internal audit
                                                                                                                      - Awareness sessions for staff on counter fraud                                                                                                                                               report 06/07 ref 2 & 15
                                                                                                                      - Whistleblowing Policy                                                                                                                                                                       Payroll, ref 3 Budgetary
                                                                                                                      - Communicated via intranet site on Fraud                                                                                                                                                     control, ref 5 cash and
                                                   C7d
                                                                                                                                                                                                                                                                                                                    bank, ref 6 creditor, ref 8
                                                   C7f
                                                                                                                                                                                                                                                                                                                    income and debtors, ref 9
                                                                                                                                                                                                                                                                                                                    capital charges, ref 10
                                                                                                                                                                                                                                                                                                                    tenders and Quotes, ref 12
                                                                                                                                                                                                                                                                                                                    General accounting, 22
                                                                                                                                                                                                                                                                                                                    charitable funds, 2007/08
                                                                                                                                                                                                                                                                                                                    ref 2 Tenders and Quotes




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                                                                                                                                                                                                COMMISSIONER ASSURANCE FRAMEWORK

Fi3   To     enhance        the    financial   SH   Y            Fi3.2   - Failure to identify spends over budget           - Contracts meetings                                                          6        #REF!          #REF! - To develop web based budgeting and purchase order         6      #REF!   - Assurance re Financial                                            No   No
      information provided to budget                            (COM)    particularly for cost per case & out of district   - Regular Reports & Invoices                                                                                processing elements within the system                                      decision making
      holders to aid efficient and effective                             spends                                             - LPCO's & Client Boards (Out of District & Continuing Care)                                                - To ensure that budget holders have received sufficient                   - Budget Reporting,
      decision making                                                                                                       - Management accountant budget monitoring                                                                   training to effectively use the new financial system                       Monitoring & Board
                                                                                                                            - Monthly financial monitoring report                                                                       - To explore the opportunities for investing in a service                  Reporting 2006/07
                                                                                                                            - Completed the implementation of the new financial systems                                                 costing system in relation to the provider arm.                            - ALE, HCS C7d
                                                        C7d                                                                                                                                                                                                                                                        - Creditors & Supplies
                                                        C7f                                                                                                                                                                                                                                                        Procedures Strategy July
                                                                                                                                                                                                                                                                                                                   2005
                                                                                                                                                                                                                                                                                                                   - Income & Debtors June
                                                                                                                                                                                                                                                                                                                   2005
                                                                                                                                                                                                                                                                                                                   - Internal Audit Report
                                                                                                                                                                                                                                                                                                                   06/07 Budgetary Control


HR3   To implement the Internal                GM   Y           HR3.1    - Failure to communicate with and engage           - Staff Survey Action Plan                                                    6        #REF!          #REF! - Redesign the order of the monthly team Brief to make      6      #REF!   - IWL Practice Plus 2006     - Monitored as part of IWL work        No   No
      Communications Strategy                                   (COM)    interest and involvement of staff resulting in     - Staff charter                                                                                             it easier to deliver & digest                                              - Staff Survey
                                                                         lack of commitment by employees to the             - Communication Strategy                                                                                    - Redevelop internal extranet & external website to
                                                                         organisation                                       - Individual/team/departmental meetings                                                                     reflect content that is needed by managers & requested
                                                                                                                            - PCT Newsletter                                                                                            by staff
                                                                                                                            - Team Brief                                                                                                - Look at success of delivery methods of
                                                                                                                            - Publications PCT Mission & Goals                                                                          communications eg notice boards, newsletter & develop
                                                                                                                            - Communications Group (internal & External)                                                                a structured system to ensure they are up to date,
                                                                                                                            - Staff Communication and Action Group                                                                      timely available & useful to staff
                                                                                                                            - implemented the action plan within the Internal Communications                                            - Use staff consultation effectively to assess the views
                                                                                                                            Strategy as detailed within the Strategy                                                                    & opinions of staff on issues that affect their working
                                                        D7                                                                                                                                                                              lives
                                                                                                                                                                                                                                        - Work with staff side representatives & IWL Group to
                                                                                                                                                                                                                                        monitor the effectiveness of all communications with
                                                                                                                                                                                                                                        staff
                                                                                                                                                                                                                                        - To implement he PCT's Internal Communications
                                                                                                                                                                                                                                        Strategy
                                                                                                                                                                                                                                        - Review HR Strategy
                                                                                                                                                                                                                                        - Electronic comms strategy
                                                                                                                                                                                                                                        - Development of external website




Fi2   To contribute to the effective           SH   Y            Fi2.1   - PCT does not achieve its statutory financial     - Operational monitoring/reporting arrangements                               5        #REF!          #REF! - Establish & role out innovative print management          5      #REF!   - Financial Accounts         - Monthly reports to the Board         No   No
      control of and achievement of                             (COM)    duties                                             - Supported the development of cost improvement programmes &                                                services, resulting in increased value for money                           Memorandum
      financial statutory duties                                                                                            saving schemes in consultation with budget managers                                                         - Turnaround Plan                                                          - Annual Audit letter
                                                                                                                            - Supported the Commissioning Directorate in the production of the                                          - To produce robust forecasts on income and                                2005/06
                                                                                                                            Local Delivery Plan & ongoing monitoring, including submissions to the                                      expenditure on a monthly basis                                             - ALE, HCS C7d
                                                                                                                            SHA                                                                                                         - To support the development of cost improvement                           - SHA monitor financial
                                                                                                                            - Developed the ability to react to changes in requirements in relation to                                  programmes and saving schemes in consultation with                         position current rating
                                                                                                                            performance management                                                                                      budget holders                                                             reduction from red to
                                                                                                                            - Supported the work in relation to Yorkshire & Humber Commercial                                           - To performance manage the organisation in respect of                     amber
                                                        C7D                                                                 Procurement to maximise benefits driven from aggregates purchasing                                          its statutory financial requirements
                                                        C7f                                                                 - Sub Board Performance and Finance Committee                                                               - To support the work in relation to Yorkshire and
                                                                                                                                                                                                                                        Humber Commercial Procurement to maximise benefits
                                                                                                                                                                                                                                        driven from aggregated purchasing
                                                                                                                                                                                                                                        - To investigate value for money opportunities through
                                                                                                                                                                                                                                        its commercial procurement strategies
                                                                                                                                                                                                                                        - To Produce robust forecasts on income & expenditure
                                                                                                                                                                                                                                        on a monthly basis



IS2   To develop information                   SH   Y          n IS2.1    The organisation does not operate within a        - annual information governance toolkit and associate improvement             5        #REF!          #REF! - Access to tiger training (Information Governance          5      #REF!   - internal audit information - information governance committee     no   No
      governance across                                        / (COM)   legal information processing framework             programme                                                                                                   training)                                                                  governance toolkit           reports to provider governance
      Commissioning                                            a                                                            - trust wide induction training on information governance                                                   - care records guarantee.                                                  - information governance committee
                                                                                                                            - IR 1 process                                                                                              - Review partnership Information Governance                                toolkit assessment sent to
                                                                                                                            - caldicott guardian appointed                                                                              arrangements                                                               information centre for
                                                                                                                            - patient consent forms                                                                                                                                                                health and social care.
                                                         C9                                                                 - consent policy                                                                                                                                                                       - HCS C9, C13c
                                                        C13c                                                                - Implemented updated information governance intranet site
                                                         D6                                                                 - Implemented improved induction slot for Information Governance
                                                                                                                            - Implemented information governance framework
                                                                                                                            - Completed information governance toolkit 2008




Fi1   To ensure the production of              SH   Y            Fi1.1   - Board not aware of financial position of the     - LDP                                                                         5        #REF!          #REF! -Produce monthly Board reports in line with local and       5 Low Risk     - Turnaround Recovery        - Monthly reports to the Board         No   No
      financial information appropriate                         (COM)    PCT, financial management compromised and          - Bi-monthly Performance & Finance Sub Committee                                                            national best practice                                                     plan
      accurate and timely                                                therefore increased chance of not meeting          - Monthly financial monitoring report to the Board                                                          - Produce external returns for the public and Strategic                    - Financial Accounts
                                                                         statutory duties                                   - Monthly Finance OMG                                                                                       Health Authority in line with relevant guidelines                          Memorandum
                                                                                                                                                                                                                                        - To provide comprehensive information regarding                           - Annual Audit letter
                                                                                                                                                                                                                                        activity costs in relation to payment by results to aid                    2005/06
                                                        C7d                                                                                                                                                                             Commissioning.                                                             - ALE, HCS C7d
                                                                                                                                                                                                                                        - In consultation with budget managers, produce robust
                                                                                                                                                                                                                                        forecasts to underpin internal & external reporting




PQ 4 Facilitate improvements in the            SB   Y           PQ 4.2   - Patients are harmed or treated unethically       - Interventional Procedures documented within clinical policies &             4        #REF!          #REF! - Continue to develop and promote the incident              4      #REF!   - HCS C5a                    - Monitoring of PCT practice against   No   No
     quality of care and services                               (COM)    through PCT failure to govern the use of new       procedures system with required competencies attached                                                       reporting system with Independent Contractors to                                                        NICE IPG Programme
                                                                         interventional procedures in Commissioned          - Interventional procedures occurred across the organisation reviewed                                       ensure that all necessary incidents are reported, and                                                   - HCS C3
                                                                         Services                                           & included in Clinical Policies & Procedure system                                                          the necessary actions taken.
                                                                                                                            - Maintain systems for the receipt of external alert notifications and
                                                        C3                                                                  processes for distribution and the monitoring of returns to independent
                                                        C5a                                                                 contractors
                                                        D4b                                                                 - In line with National and Local Guidance negotiated and agreed
                                                                                                                            quality standards between the PCT and its independent contractors
                                                                                                                            and commissioned services
                                                                                                                            - To monitor quality standards via review visits and quality tools



Fi3   To     enhance     the   financial       SH   Y            Fi3.1   - PCT not able to respond to the modernisation - Disaster Recovery Plan                                                          4        #REF!          #REF! - Develop web based budgeting & purchase order              4      #REF!   - Internal Audits of main                                           No   No
      information provided to budget                            (COM)    agenda. PCT not able to access timely          - Debtors & Income system                                                                                       processing elements within the system                                      financial systems & action
      holders to aid efficient and                                       financial information                          - Capital charges system                                                                                        - To develop web based budgeting and purchase order                        plans
      effective decision making                                                                                         - New ledger system 'Great Plains' installed 01.04.06                                                           processing elements within the system                                      - HCS C7d, ALE
                                                        C7d                                                             - Completed the implementation of the new financial systems                                                     - To ensure that budget holders have received sufficient
                                                        C7f                                                                                                                                                                             training to effectively use the new financial system




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                                                                                                                                                                                          COMMISSIONER ASSURANCE FRAMEWORK

Fi4   To respond to the business          SH   Y          n Fi4.1   PCT is not able to respond to current business - Competent trained workforce with qualified accountants and support             4        #REF!          #REF!                                                                 4   #REF!   - Internal audit reports        - Board monthly finance reports       No   No
      requirements       of       PCT                     / (COM)   requirements                                   structures                                                                                                                                                                                 - Accounting and general
      Commissioners and Providers by                      a                                                        - Financial information and budget management accountability structure                                                                                                                     ledger and accounting
      influencing and supporting areas                                                                             - Director of Finance                                                                                                                                                                      functions
      of development                                                                                               - Reviewed the current arrangements for the finance function to support                                                                                                                    - District Audit opinions
                                                   C7d                                                             both elements of the PCT                                                                                                                                                                   - SHA monthly reporting
                                                   C7f                                                             - Ensured staff have the tools to work effectively in their respective                                                                                                                     - HCS C7d, ALE
                                                                                                                   roles




PQ 8 Manage the planning process          SB   Y           PQ 8.1   - Lack of strategic direction & planning in the - Business Planning Training                                                    3        #REF!          #REF! - Provide business planning training to PCT staff as            3   #REF!   - Head of Internal Audit        - Business plan to the Board          No   No
     and its integration with the                          (COM)    Commissioning Function of the PCT               - Business Planning Framework                                                                                 appropriate.                                                                Opinion Statement Audit
     Assurance Framework/Risk                                                                                       - Support from Performance & Quality to Commissioning function to                                                                                                                         Committee reviewed
     Register                                                                                                       develop Business Plans                                                                                                                                                                    -Fitness for Purpose
                                                                                                                    - Quarterly Performance Reviews                                                                                                                                                           review and action plan
                                                                                                                    - Business planning guidance is refined & updated annually                                                                                                                                - HCS C7a, C7c
                                                                                                                    - Business planning training is available to PCT staff
                                                                                                                    - Business plan is linked to the assurance framework
                                                                                                                    - Submit the business plan for Board approval
                                                                                                                    - Ensured the business planning framework and matrix is updated as
                                                   C7a                                                              appropriate and distribute.
                                                   C7c                                                              - Facilitated the development of the Commissioning Annual Plan and
                                                                                                                    supporting local plans as appropriate.
                                                                                                                    - Ensured that the Commissioning Annual Plan is linked to the
                                                                                                                    Assurance Framework and strategic goals, objectives and Healthcare
                                                                                                                    Standards
                                                                                                                    - Submitted the Plan to the PCT Board for approval




PQ 8 Manage the planning process          SB   Y           PQ 8.2   - Failure of the PCT to put in place effective     - Separate Consideration of AF by Non-executive Directors                    3        #REF!          #REF!                                                                 3   #REF!   - SHA approved                  - Assurance Framework considered by No     No
     and its integration with the                          (COM)    corporate governance systems to regulate the      - Assurance Framework & associated Risk Register Developed                                                                                                                              Assurance Framework             Audit Committee
     Assurance Framework/Risk                                       business & ensure the adequacy of the PCTs        - system in place for identifying principal risks from Main Committee                                                                                                                   - Audit Commission              - Assurance Framework submitted to
     Register                                                       system of Internal Control                        structures To add To Assurance Framework                                                                                                                                                approval for Assurance          the Board
                                                                                                                      - Ensured that the Commissioning annual Plan is linked To the                                                                                                                           Framework category A
                                                                                                                      Assurance Framework and strategic goals, objectives and healthcare                                                                                                                      status
                                                                                                                      standards                                                                                                                                                                               - Governance
                                                                                                                      - Submitted the Plan To the PCT Board for approval                                                                                                                                      Arrangements
                                                                                                                                                                                                                                                                                                              memorandum 2003/04
                                                                                                                                                                                                                                                                                                              - HoIA Statement Audit
                                                                                                                                                                                                                                                                                                              Committee reviewed
                                                   C7a                                                                                                                                                                                                                                                        - Internal Audit verification
                                                   C7c                                                                                                                                                                                                                                                        of PCT Assurance
                                                                                                                                                                                                                                                                                                              Framework
                                                                                                                                                                                                                                                                                                              - Statement on Internal
                                                                                                                                                                                                                                                                                                              Control
                                                                                                                                                                                                                                                                                                              - ALE
                                                                                                                                                                                                                                                                                                              - Internal Audit report
                                                                                                                                                                                                                                                                                                              2006/07 ref 11 Risk
                                                                                                                                                                                                                                                                                                              management
                                                                                                                                                                                                                                                                                                              - HCS C7a, C7c


IS5   Modernise the existing PCT          SH   Y          n IS5.2   Organisation unable to attract and retain staff   - Approved Infrastructure Deployment Plan for 2007/08 - aligned to            3        #REF!          #REF!                                                                 3   #REF!                                   - PRINCE Project monitored by Mpfit   No   No
      Infrastructure with a fit for                       / (COM)                                                     other Business Objectives                                                                                                                                                                                               Board
      Purpose Infrastructure                              a                                                           - Approved allocation of capital funding required for second Phase of
                                                                                                                      the project
                                                    D6                                                                - Redevelopment of Intranet site
                                                   C8a                                                                - Tendered for additional power/network sockets contract's)
                                                   C8b                                                                - Continual assessments of deployment plan for 2007/08 against
                                                   C11c                                                               business objectives
                                                   D5A                                                                - Implementation of IT equipment replacement programme
                                                    D7                                                                - Implementation and monitoring of additional power and networking
                                                                                                                      based on site specific requirements against plan



      To    develop    the  use   of      SH   Y            IS3.4   - Organisation unable to provide information      - PRIMIS, routine data extracts & reports                                     3        #REF!          #REF! - Identification of technical solutions to fill gaps required   3   #REF!   - National PRIMIS         - Template Group reports to                 No   No
      information systems In Primary                       (COM)    from Primary Care to support key business         - Template Development Programme/Minimum Datasets incorporating                                             for warehousing & analysis improvement                                      Standard and process      Information Governance
      Care                                                          requirements, especially activity recording       New GMS contract datasets                                                                                   - Develop PCT data quality policy                                           - GPSOC accreditation for
                                                                                                                      - QMAS reports re: QOF clinical domain data                                                                                                                                             Primary Care systems
                                                                                                                      - Public Health based inequality profiling
                                                                                                                      - Ongoing clinical audit programme
                                                   D6                                                                 - Practice Based Commissioning Data
                                                                                                                      - Additional PRIMIS Facilitator post funded from April 2007
                                                                                                                      - Received IM&T DES plans from each practice
                                                                                                                      - Established a monitoring process for IM&T DES



Fi1   To ensure the production of         SH   Y            Fi1.2   - Failure to agree budget at commencement of      - Budget setting process locally & with SHA to ensure timely sign off of      3        #REF!          #REF! - Produce external returns for the public and Strategic         3   #REF!   - Budget Setting process                                              No   No
      financial information appropriate                    (COM)    financial year                                    LDP                                                                                                         Health Authority in line with relevant guidelines                           with SHA
      accurate and timely                                                                                                                                                                                                         - In consultation with budget managers produce robust                       - ALE HCS C7d
                                                                                                                                                                                                                                  forecasts to underpin internal and external reporting                       - internal audit report
                                                   C7d                                                                                                                                                                            - To provide comprehensive information regarding                            06/07 ref 3 Budgetary
                                                   C7f                                                                                                                                                                            activity costs in relation to payment by results to aid                     control,
                                                                                                                                                                                                                                  Commissioning.




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                                                                                                                                                                                        COMMISSIONER ASSURANCE FRAMEWORK

Fi5   To further develop HR plans for     SH   Y           Fi5.1   - Finance Department fails to be fit for purpose - SDR                                                                         3        #REF!          #REF! - To continue to promote work life balance opportunities    3   #REF!   - ALE                      No   No
      the directorate ensuring that the                   (COM)                                                     - Reviewed staffing structure in line with current service model                                            and improving working lives initiatives within the needs                - Fit For Purpose review
      directorate has the right skills                                                                              - Review & adopt current best practice                                                                      of the service                                                          and action plan
      and abilities to meet the PCTs                C7                                                              - Promote training opportunities that meet the individuals, the                                             - To promote training opportunities that meet the                       - District Audit letter
      objectives                                   C8a                                                              departments& the PCTs needs                                                                                 individuals and organisations needs.                                    - Internal Audit reports
                                                   C8b                                                              - Promote an environment that is fit for purpose & is consistent with the                                   - To promote an environment that is fit for purpose and                 Financial Systems
                                                   C10a                                                             PCT Health & Safety policies                                                                                is consistent with the PCT Health and Safety policies
                                                   C10b                                                             - Reviewed staffing levels in accordance with service demands taking                                        - To ensure staff appraisals are performed in
                                                   C11a                                                             account of business risks and objectives                                                                    accordance with HR policy
                                                   C11b                                                                                                                                                                         - To continue to promote work life balance opportunities
                                                   C11c                                                                                                                                                                         & improving working lives initiatives within the needs of
                                                                                                                                                                                                                                the service




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                                                                                                                                                                                                                                         CARE SERVICES ASSURANCE FRAMEWORK




Objective Number




                                                                                         Care Services
 Business Unit




                                                                         Lead Director




                                                                                                                    Risk Number




                                                                                                                                                                                                                                                                                            Traffic Light




                                                                                                                                                                                                                                                                                                                                                                                                             Traffic Light
                                                                                                                                                                                                                                                               Risk Rating




                                                                                                                                                                                                                                                                                                                                                                           Risk Rating
                                                                                                         Mapped                                                                                                                                                                                                                                                                          Residual Risk                        Assurance - External           Internal Management                                Gaps in
                              DIRECTORATE OBJECTIVE                                                                                                 RISK                                                  Existing Controls                                                  Risk Rating                                         Planned Controls                                                                                                                                       Gaps In Control
                                                                                                         to HCS                                                                                                                                                                                                                                                                             Rating                             (inc Internal Audit)               Assurance                                    Assurance



  SI2              Achieve cost reduction programme                      SR               Y                       SI2.1           Financial risk to Provider Unit if cost - Plans developed across service areas to achieve cost                               25              #REF!       #REF!                                                                           20               #REF!          #REF!             - Annual auditors review    - PCT Board and Care           No                No
                                                                                                                  (CS)            reduction programme not achieved reduction targets                                                                                                                                                                                                                                         of accounts                 Services Board PIA JAG
                                                                                                          C7d                     potentially leading to overspend        - Developed plans to achieve the cost reduction targets                                                                                                                                                                                            - HCS C7d - ALE             - MH Steering Group
                                                                                                                                                                          - Implemented Plans

PQ 2               Develop and test emergency plans across the PCTs      SB               Y                       PQ 2.1 - Failure of Care Services Unit to                    - Barnsley PCT Emergency Planning Group                                         15              #REF!       #REF!            - Review the Care Services business continuity plan            10               #REF!          #REF!             - District Audit review     - May 07 testing of "on call   No                No
                   Care Services to comply with the Healthcare                                                     (CS) respond effectively to any emergency                   - Care Services Emergency Planning Group & Annual Action                                                                     - Test Mass Treatment Plan                                                                                       2007                        system"
                   Commission requirements and the Civil                                                                 situation                                             Plan                                                                                                                         - Develop evacuation plans for PCT Care Services sites                                                                                       - Sept 07 live multi-agency
                   Contingencies Act                                                                                                                                           - BPCT Corporate Resilience Plan                                                                                             - Update the Emergency Incident Escalation Plan                                                                                              exercise
                                                                                                                                                                               - Outbreak Plan. Chemical Incident Plan, Deliberate Biological                                                               - Ensure Care Services Emergency Arrangements/Plans fit                                                                                      - HCS C24
                                                                                                                                                                               & Radioactive Agents, Mass Vaccination Plan, Flu Pandemic                                                                    into PCT wide plans and maintain continued representation
                                                                                                                                                                               Plan, Business Continuity Plan                                                                                               of the Directorate at the PCT wide group
                                                                                                                                                                               - Estates Emergency Plans
                                                                                                                                                                               - Business Analysis & Continuity Plan templates
                                                                                                                                                                               - Mass Treatment Group
                                                                                                                                                                               - Scenario Risk Assessment
                                                                                                                                                                               - Control of Infection Major Outbreak Plan
                                                                                                                                                                               - All Care Services completed business impact analysis &
                                                                                                          C24                                                                  continuity plan templates. Prioritised programme of
                                                                                                                                                                               development underway
                                                                                                                                                                               - Practice Group addressing emergency planning/business
                                                                                                                                                                               continuity in general practice
                                                                                                                                                                               - Care Services arm's business continuity plan
                                                                                                                                                                               - Communicated Heatwave Plan to Service Managers and GP
                                                                                                                                                                               practices
                                                                                                                                                                               - Tested the Care Services business continuity plan
                                                                                                                                                                               - Rolled out the business continuity plan training for the PCTs
                                                                                                                                                                               Care Services
                                                                                                                                                                               - Contributed to the development of an exercise test
                                                                                                                                                                               programme including table top and live


   P7              Ensure robust Governance arrangements around          MK               Y                        P7.1           Risk of compromised patient safety           - Cleanliness -                                                                 15              #REF!       #REF!                                                                           10               #REF!          #REF!             - Acceptance by HCC of      - Reports to Provider          No                No
                   Infection control issues in all Business Units                                                  (CS)           within Care Services and all Providers       - Environmental Health Hygiene Inspections                                                                                                                                                                                                    infection control           Governance Committee, PCT
                                                                                                                                                                               - Internal Monitoring of Kitchen Hygiene Standards
                   involved with Patient Care and within all Providers                                                            leading to a risk of potential litigation    - Training on Induction and Regular Updates
                                                                                                                                                                                                                                                                                                                                                                                                                             declaration in Health       Board re implementation of
                   (For Commissioning and Care Services)                                                                          and complaints around infection control.     - SLA for Infection Control Team                                                                                                                                                                                                              Care Standards              infection control action plan
                                                                                                                                                                               - Infection Control Work programme                                                                                                                                                                                                            declaration in April 2007   - Reports of incidents targets
                                                                                                                                                                               - Matrons Charter                                                                                                                                                                                                                             - Risk Management Audit     to Care Services Board
                                                                                                                                                                               - Clean Hands campaign                                                                                                                                                                                                                        2006/07 No. 11
                                                                                                                                                                               - Infection Control Policies
                                                                                                                                                                               - Promotional Events i.e. Hand Hygiene
                                                                                                                                                                                                                                                                                                                                                                                                                             - HCS C4a, C4c, C21
                                                                                                                                                                               - Decontamination process of Home Loans Equipment Monitored                                                                                                                                                                                   - HPA C Diff, MRSA
                                                                                                                                                                               - Action plan to control C. Dif                                                                                                                                                                                                               - SHA - Spending Plan
                                                                                                          C1a
                                                                                                                                                                               - Strategic Cleaning Plan
                                                                                                          C1b                                                                  - Action Plan to meet Health Care Act
                                                                                                          C4a                                                                  - Reviewed the Care Services business continuity plan
                                                                                                          C4b                                                                  - Tested the Care Services business continuity plan
                                                                                                          C4c                                                                  - Rolled out the business continuity plan training for the PCTs Care Services
                                                                                                                                                                               - Tested Mass Treatment Plan
                                                                                                          C4e                                                                  - Developed evacuation plans for PCT Care Services sites
                                                                                                          C21                                                                  - Updated the Emergency Incident Escalation Plan
                                                                                                          D1                                                                   - Contributed to the development of an exercise test programme including
                                                                                                                                                                               table top and live
                                                                                                                                                                               - Ensured Care Services Emergency Arrangements/Plans fit into PCT wide
                                                                                                                                                                               plans and maintain continued representation of the Directorate at the PCT
                                                                                                                                                                               wide group
                                                                                                                                                                               - Monitored progress of infection control against work programme and
                                                                                                                                                                               associated action plan
                                                                                                                                                                               - Monitored performance againist MRSA and CDiff targets
                                                                                                                                                                               - Ensured audit programme reflects infection control issues
                                                                                                                                                                               - Rolled out essential steps programme
                                                                                                                                                                               - Monitored additional payment monies (SHA) against agreed targets
                                                                                                                                                                               - Reviewed infection control services within the PCT
  IS9              Planning and implementation of key information        SH               Y                       IS9.2           - Risk to patient care if records are        - Business Continuity procedures                                                10              #REF!       #REF!            - Completion of replacement of legacy systems with modern           5           #REF!        Green               - SHA programme                                            No                No
                   systems to support PCT business objectives                                                      (CS)           incomplete, inaccessible or corrupted        - IMT disaster recovery                                                                                                      Npfit systems including transfer to centralised system                                                           management and
                   including Mental Health CPA and replacement of                                                                                                              - Help desk fault logging and resolution service                                                                             servers.                                                                                                         assurance
                   legacy McKesson systems                                                                                                                                     - IT SLA with external service provider                                                                                      - PCT infrastructure project                                                                                     - HCS C9
                                                                                                                                                                               - information governance work programme
                                                                                                                                                                               '- Developed the programme plan for system replacement
                                                                                                                                                                               implementation
                                                                                                          C9                                                                   - Developed a specific project initiation document for PAS/TCS
                                                                                                          D6                                                                   replacement
                                                                                                                                                                               - Developed a specific project initiation document for specialist
                                                                                                                                                                               community services and child health
                                                                                                                                                                               - Engagement with PCT provider services in the project
                                                                                                                                                                               planning and implementation
                                                                                                                                                                               - Wider Rollout of eSAP (TBC)


  IS2              To develop information governance across Care SH                       Y                       IS2.3           - The PCT breaches patient                   - Complaints, Claims and Serious Untoward Incidents Sub                         10              #REF!       #REF!            - Manage & store records in accordance with NHS IG             10               #REF!          #REF!             - Achievement of            - 1/4ly reports from           No                No
                   Services                                                                                        (CS)           confidentiality leading to                   Group identifies area of poor practice & trends & ensures                                                                    Toolkit                                                                                                          compliance with the NHS     Complaints, Incidents &
                                                                                                                                  complaints/litigation through failure to     change occurs                                                                                                                - Confidentiality Code of Conduct                                                                                Information Governance      Claims Sub Group to the
                                                                                                                                  treat patient's information confidentially   - Systems in place to deal with poor performance of individuals                                                              - Review of medical records within the PCT underway                                                              Toolkit (Records            Provider Governance
                                                                                                                                  & provide information on the use &           - Staff induction programme includes data protection &                                                                       (including storage)                                                                                              Management)                 Committee
                                                                                                                                  disclosure of confidential information       information sharing presentation                                                                                             - Implementing care record guarantee                                                                             - Internal Audit report     - 1/4ly report to Board from
                                                                                                                                  held about them.                             - Patient Information leaflet                                                                                                                                                                                                                 06/07 Info Governance       Primary Care Reference
                                                                                                                                                                               - Implemented updated information governance intranet site                                                                                                                                                                                    - HCS C13b, C13c            Committee
                                                                                                          C13b                                                                 - Implemented improved induction slot for Information                                                                                                                                                                                                                     - Information Governance
                                                                                                          C13c                                                                 Governance                                                                                                                                                                                                                                                                Toolkit Self Assessment
                                                                                                                                                                               - Implemented information governance framework
                                                                                                                                                                               - Completed information governance toolkit 2008
                                                                                                                                                                               - Reviewed partnership Information Governance arrangements




  IS2              To develop Information Governance across Care         SH               Y                       IS2.2            The organisation does not operate           - Annual information governance toolkit and associate                                5          #REF!       #REF!            - access to tiger training (information governance training)        5           #REF!                            - internal audit          - information governance   no                      No
                   Services                                                                                        (CS)           within a legal information processing        improvement programme                                                                                                        - care records guarantee.                                                                                        information governance committee reports to Provider
                                                                                                                                  framework and patient care cannot be         - Trust wide induction training on Information Governance                                                                                                                                                                                     toolkit                   Governance Committee
                                                                                                                                  safely provided.                             - IR 1 process                                                                                                                                                                                                                                - information governance
                                                                                                                                                                               - Caldicott Guardian appointed                                                                                                                                                                                                                toolkit assessment sent
                                                                                                                                                                               - Patient consent forms                                                                                                                                                                                                                       to information centre for
                                                                                                                                                                               - Consent Policy                                                                                                                                                                                                                              health and social care.
                                                                                                           C9                                                                  - Implemented updated Information Governance intranet site                                                                                                                                                                                    - HCS C9, C13c
                                                                                                          C13c                                                                 - Implemented improved induction slot for Information
                                                                                                           D6                                                                  Governance
                                                                                                                                                                               - Implemented Information Governance framework
                                                                                                                                                                               - Completed Information Governance toolkit 2008
                                                                                                                                                                               - Reviewed partnership Information Governance arrangements




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Objective Number




                                                                                         Care Services
 Business Unit




                                                                         Lead Director




                                                                                                                   Risk Number




                                                                                                                                                                                                                                                                                   Traffic Light




                                                                                                                                                                                                                                                                                                                                                                                                     Traffic Light
                                                                                                                                                                                                                                                   Risk Rating




                                                                                                                                                                                                                                                                                                                                                                   Risk Rating
                                                                                                         Mapped                                                                                                                                                                                                                                                                  Residual Risk                        Assurance - External         Internal Management                                 Gaps in
                              DIRECTORATE OBJECTIVE                                                                                                 RISK                                              Existing Controls                                          Risk Rating                                            Planned Controls                                                                                                                                       Gaps In Control
                                                                                                         to HCS                                                                                                                                                                                                                                                                     Rating                             (inc Internal Audit)             Assurance                                     Assurance



  Fi2              To contribute to the effective control of and SH                       Y                       Fi2.1          - PCT does not achieve its statutory           - Operational monitoring/reporting arrangements                         5          #REF!         #REF!             - Establish & role out innovative print management                   5           #REF!          #REF!             - Financial Accounts      - Monthly reports to the Board No                 No
                   achievement of all PCT financial statutory duties                                              (CS)           financial duties                               - Supported the development of cost improvement                                                                    services, resulting in increased value for money                                                                  Memorandum
                                                                                                                                                                                programmes & saving schemes in consultation with budget                                                            - To support the work in relation to Yorkshire and Humber                                                         - Annual Audit letter
                                                                                                                                                                                managers                                                                                                           Commercial Procurement to maximise benefits driven from                                                           - ALE (C7d)
                                                                                                                                                                                - Supported the Commissioning Directorate in the production                                                        aggregated purchasing                                                                                             - SHA monitor financial
                                                                                                                                                                                of the Local Delivery Plan & ongoing monitoring, including                                                         - To Produce robust forecasts on income & expenditure on                                                          position current rating
                                                                                                                                                                                submissions to the SHA                                                                                             a monthly basis                                                                                                   reduction from red to
                                                                                                                                                                                - Developed the ability to react to changes in requirements in                                                     - To support the development of cost improvement                                                                  amber
                                                                                                                                                                                relation to performance management                                                                                 programmes and saving schemes in consultation with
                                                                                                          C7D                                                                   - Sub Board Performance and Finance Committee                                                                      budget holders
                                                                                                          C7f                                                                   - Turnaround Plan                                                                                                  - To Performance manage the organisation in respect of its
                                                                                                                                                                                - Produced robust forecasts on income and expenditure on a                                                         statutory financial requirements
                                                                                                                                                                                monthly basis                                                                                                      - To Support the work in relation to Yorkshire & Humber
                                                                                                                                                                                                                                                                                                   Commercial Procurement to maximise benefits driven from
                                                                                                                                                                                                                                                                                                   aggregates purchasing
                                                                                                                                                                                                                                                                                                   - To investigate value for money opportunities through its
                                                                                                                                                                                                                                                                                                   commercial procurement strategies



  Fi1              To ensure the production of financial information that SH              Y                       Fi1.1          - Board not aware of financial position of     - LDP                                                                   5          #REF!         #REF!             - To provide comprehensive costing information to enable             5 Low Risk               Dark Green - Turnaround Recovery              - Monthly reports to the Board No                 No
                   is appropriate, accurate and timely                                                            (CS)           the PCT, financial management                  - Bi-monthly Performance & Finance Sub Committee                                                                   the Provider Unit to make strategic business decisions                                                   plan
                                                                                                                                 compromised and therefore increased            - Monthly financial monitoring report to the Board                                                                 - In consultation with budget managers, produce robust                                                   - Financial Accounts
                                                                                                                                 chance of not meeting statutory duties         - Monthly Finance OMG                                                                                              forecasts to underpin internal & external reporting                                                      Memorandum
                                                                                                                                                                                - consulted with budget managers produce robust forecasts to                                                       - Produce monthly board reports in line with local and                                                   - Annual Audit letter
                                                                                                                                                                                underpin internal and external reporting                                                                           national best practice                                                                                   - ALE (C7d)
                                                                                                          C7d                                                                   - Provided comprehensive information regarding activity costs                                                      - Produce external returns for the public and SHA in line
                                                                                                                                                                                in relation to payment by results to aid Commissioning.                                                            with relevant guidelines.




  SI3              Secure Service Level Agreements/Contracts with all SR                  Y                       SI3.1          Failure to secure service income               - All service provided within a framework of SLAs/Contracts        12 High Risk                Yellow              - Ensure all SLA's are signed off                                    8           #REF!          #REF!             - HCS C7d - ALE           - Benchmarking comparing        No                No
                   Service Commissioners                                                                          (CS)                                                          with income secured for service provision                                                                          - Ensure that any outstanding SLA are signed off (See SLA                                                                                   with other providers
                                                                                                          C7d                                                                                                                                                                                      inventory)                                                                                                                                  - Reporting process to Care
                                                                                                          C18                                                                                                                                                                                                                                                                                                                                  Services Board
                                                                                                          C22a                                                                                                                                                                                                                                                                                                                                 - Contract GP monitoring
                                                                                                          C22b                                                                                                                                                                                                                                                                                                                                 - Invoice monitoring via
                                                                                                          C22c                                                                                                                                                                                                                                                                                                                                 Finance function
                                                                                                                                                                                                                                                                                                                                                                                                                                               - Audit Committee

  IS3              Planning and Implementation of improvement to SH                       Y                       IS3.3          - Failure of the PCT to effectively            - Commercial offsite facility available (Leeds)                    12              #REF!         #REF!              - Procedure for creation, storage and disposal of records to        8           #REF!          #REF!             - NHSLA Level 1B          - Records Management            Yes             No
                   support PCT health records management                                                           (CS)          manage the storage, retrieval &                - Records Management Policies                                                                                      all staff by end 07/08                                                                                            Records Management        Report on Progress re Toolkit   - Expand record
                                                                                                                                 destruction of health records in               - Information Governance Officer appointed                                                                         - Development of Policy by year end 08/09                                                                         Criteria                  to Corporate Governance         keeping to
                                                                                                                                 impacting on the service the PCT               - Creation of additional storage on Kendray Hospital site                                                          - Procurement of PCT records management system                                                                    - NHS Information         - Action plan reviewed by       include
                                                                                                                                 provides to patients (missing/                 - Information Governance Policy                                                                                    - Implementation of PCT records management system                                                                 Authority review          Information Governance          destruction &
                                                                                                                                 misplaced/duplicated notes etc) and            - Health Records Policy                                                                                            08/09                                                                                                             - Internal Audit report   Committee & Provider            availability of
                                                                                                                                 resulting in potential complaints/litigation   - PCT Confidentiality Policy & Code of Conduct                                                                                                                                                                                       06/07 Info Governance     Governance Committee            records to be
                                                                                                                                                                                - Procedure on storage & destruction of records                                                                                                                                                                                      - HCS C9                                                  resolved by end
                                                                                                                                                                                - IR1 systems for reporting non-availability of notes                                                                                                                                                                                                                                          of 07/08
                                                                                                                                                                                 Targeted information governance toolkit compliance level 2                                                                                                                                                                                                                                    procedure
                                                                                                                                                                                for all items by 2007 submission
                                                                                                          C9
                                                                                                                                                                                - Integrated Information Governance within 'Integrated
                                                                                                                                                                                Governance' approach in PCT
                                                                                                                                                                                - Produced a Business case for PCT centralised records
                                                                                                                                                                                service
                                                                                                                                                                                - Records digitisations options, separate to but linked to
                                                                                                                                                                                Business Case for PCT records service
                                                                                                                                                                                - Develop corporate approach to operational service control of
                                                                                                                                                                                records



  IS2              To develop Information Governance across Care        SH                Y                       IS2.1          - Organisation unable to modernise             - Project management function within Information Systems           12              #REF!         #REF!             - Alignment of Information Service to future re-organisation         8           #REF!                            - ICES (Homeloans)        - Replaced Finance System     No                  No
                   Services                                                                                        (CS)          information systems and therefore              - PCT has structured a Board Level post ensuring appropriate                                                       of the organisation                                                                                               - Choose & Book           (ledgers) Replaced HR/Payroll
                                                                                                                                 unable to meet commissioner service            prioritisation - Director of Information Services                                                                                                                                                                                    - Connecting for Health   System
                                                                                                                                 specifications (for Commissioner and           - Agreed use of captial funding through NRAC                                                                                                                                                                                         (CFH)
                                                                                                                                 Care Services)                                 - Governance via PRINCE & PCT NPfIT Board                                                                                                                                                                                            - Care Records Service
                                                                                                                                                                                - Implemented updated information governance intranet site                                                                                                                                                                           in Mental Health
                                                                                                                                                                                - Implemented improved induction slot for Information                                                                                                                                                                                - ESR
                                                                                                                                                                                Governance
                                                                                                                                                                                - Information Governance Toolkit 2007
                                                                                                           C9                                                                   - Implemented information governance framework
                                                                                                          C13c                                                                  - Information Governance Workstreams
                                                                                                           D6                                                                   - Completed information governance toolkit 2008
                                                                                                                                                                                - Reviewed partnership Information Governance arrangements




  IS1              Planning and Implementation of improvement to the    SH                Y                       IS1.1          - Organisation unable to modernise             - Project management function within Information Systems           12              #REF!         #REF!             - 2007/08 Npfit implementation programme                             8           #REF!          #REF!             - ICES (Homeloans)        - Replaced Finance System       No                No
                   day to day support for PCT information systems                                                  (CS)          information systems and therefore              - PCT has structured a Board Level post ensuring appropriate                                                       - Alignment of information service to future re-organisation                                                      - Choose & Book           (ledgers)
                                                                                                                                 unable to meet PCT and commissioner            prioritisation - Director of Information Services                                                                  of the organisation                                                                                               - Connecting for Health    - Replaced HR/Payroll
                                                                                                                                 service specifications                         - Agreed use of capital funding through NRAC                                                                       - Continual assessments of deployment plan for 2007/08                                                            (CFH)                     System
                                                                                                                                                                                - Governance via PRINCE & PCT NPfIT Board                                                                          against business objectives                                                                                       - Care Records Service    - PRINCE project assurance
                                                                                                                                                                                - Implemented an IT SLA management framework                                                                       - Implementation of IT equipment replacement programme                                                            in Mental Health          monitored by Nfit Board
                                                                                                          C13c                                                                  - Implemented the information services work programme                                                              - Implementation and monitoring of additional power and                                                           - ESR
                                                                                                           D6                                                                   procedure                                                                                                          networking based on site specific requirements against plan                                                       - External audit
                                                                                                                                                                                - Strategy developed for linking staff on BMBC sites to PCT                                                                                                                                                                          2006/2007 ref 4 IT
                                                                                                                                                                                network - Agreed 01/11/07                                                                                                                                                                                                            Disaster Recovery Plan
                                                                                                                                                                                - Implemented Business Continuity Procedure




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Objective Number




                                                                                             Care Services
 Business Unit




                                                                             Lead Director




                                                                                                                        Risk Number




                                                                                                                                                                                                                                                                                   Traffic Light




                                                                                                                                                                                                                                                                                                                                                                                                      Traffic Light
                                                                                                                                                                                                                                                      Risk Rating




                                                                                                                                                                                                                                                                                                                                                                    Risk Rating
                                                                                                             Mapped                                                                                                                                                                                                                                                               Residual Risk                        Assurance - External           Internal Management                                Gaps in
                               DIRECTORATE OBJECTIVE                                                                                                    RISK                                             Existing Controls                                          Risk Rating                                         Planned Controls                                                                                                                                         Gaps In Control
                                                                                                             to HCS                                                                                                                                                                                                                                                                  Rating                             (inc Internal Audit)               Assurance                                    Assurance



  IS9              Planning and Implementation of key information            SH               Y                       IS9.1           Organisation unable to provide              '- Developed the programme plan for system replacement              12              #REF!       #REF!                                                                                  8           #REF!        Green               '- Internal Audit Board     - OMG Monthly monitoring of    No                No
                   systems to support PCT business objectives                                                          (CS)           information to support key business         implementation                                                                                                                                                                                                                      Activity Audit              activity trends and outliers
                   including Mental Health CPA and replacement of                                                                     requirements, especially activity           - Data Quality report and regular business item on joint
                   legacy McKesson systems                                                                                            recording                                   management team meeting
                                                                                                                                                                                  - Developed a specific project initiation document for PAS/TCS
                                                                                                              C9                                                                  replacement
                                                                                                              D6                                                                  - Applied PRINCE project management to all projects
                                                                                                                                                                                  - Developed a specific project initiation document for specialist
                                                                                                                                                                                  community services and child health
                                                                                                                                                                                  - Engagement with PCT provider services in the project
                                                                                                                                                                                  planning and implementation
                                                                                                                                                                                  - Wider Roll out of eSAP (TBC)

PQ 1               Develop performance management systems and                SB               Y                       PQ 1.1 - Failure to achieve performance targets - Weekly monitoring of waiting times - STEIS report                             12              #REF!       #REF!            - Successfully negotiate service level agreements between 12                      #REF!          #REF!             - Audit Commission          - Monthly provider              No               No
                   processes for PCT Care Services, to facilitate the                                                  (CS) and generate income of the provider       - Waiting list trigger protocol                                                                                              the PCT as a provider and other provider PCTs and NHS                                                              Report "Performance         performance management
                   delivery of performance targets and compliance with                                                       PCT                                      - Monthly provider performance management reports to Joint                                                                   organisations                                                                                                      Management" - Provider      reports to the Care Services
                   contracts                                                                                                                                          Managers Meeting, PCT, Care Services Operational Directors                                                                   - Ensure the timely and accurate submission of care                                                                Services                    Board
                                                                                                                                                                      Group                                                                                                                        services (provider) returns to the Strategic Health Authority,                                                                                 - 1/4ly reports to the Board on
                                                                                                                                                                      - Service manager action plans to address underperformance                                                                   Department of Health, Healthcare Commission and other                                                                                          Annual Health Check
                                                                                                                                                                      - Quarterly monitoring of the annual business plan                                                                           PCTs                                                                                                                                           - HCS C7f
                                                                                                                                                                      - Monthly/Quarterly reporting of activity returns (validation &                                                              - Further develop performance monitoring systems to
                                                                                                                                                                      director sign off)                                                                                                           monitor the performance of the PCT Care Services and the
                                                                                                                                                                      - Contract monitoring meetings with neighboring PCTs                                                                         annual health check targets
                                                                                                                                                                      - Contract Monitoring meetings between commissioner and                                                                      - Ensure that the performance systems alert the PCT to any
                                                                                                                                                                      Care Services                                                                                                                significant under or over performance and ensure action
                                                                                                              C7a?                                                    - Minutes of Care Services Contract Team & SLA inventory                                                                     plans are put in place to undertake remedial action
                                                                                                               C7f                                                    - Service Improvement review meetings                                                                                        - Ensure that the Care Services Board continue to receive
                                                                                                                                                                      - Director sign off process                                                                                                  timely and accurate monthly provider performance
                                                                                                                                                                      - Client Board balanced scorecards & performance sub group                                                                   management reports and the Board quarterly annual health
                                                                                                                                                                      minutes                                                                                                                      check reports
                                                                                                                                                                                                                                                                                                   - Ensure that there is continued representation from the
                                                                                                                                                                                                                                                                                                   Directorate on the client board performance sub groups
                                                                                                                                                                                                                                                                                                   - Ensure that the Care Services Board continues to receive
                                                                                                                                                                                                                                                                                                   quarterly business plan performance reports




PQ 4               Ensure that the PCT has effective Governance              SB               Y                       PQ 4.1 Safety    of    patients    &     clinical           - Clinical Governance Strategy                                      12              #REF!       #REF!            - To develop and implement a governance system (for                   8           #REF!          #REF!             - Internal audit report     - Routine monitoring of        No                No
                   arrangements in place to mitigate risk to the                                                       (CS) effectiveness is compromised through                  - Clinical Governance awareness workshop                                                                         policies and procedures) within the PCT                                                                            2006/07 ref 11 Risk         progress by Governance
                   organisation in accordance with national guidance                                                         failure to put in place corporate                    - PCT Governance Committee                                                                                       - To provide required statutory documents and appropriate                                                          Management                  Committee
                                                                                                              C1a
                                                                                                                             arrangements & structures for clinical               - Quality Leads                                                                                                  governance reports, for example the assurance framework,                                                           - Medicines Management      - Provider Governance
                                                                                                              C1b
                                                                                                                             governance resulting in failure to                   - PCT wide Quality Framework                                                                                     the statement on internal control and risk management                                                              follow up 2007/08 ref 7     Committee minutes to Care
                                                                                                              C7a
                                                                                                                             continuously improve quality of services             - Clinical Governance 1/4ly reporting - as part of business plan                                                 annual reports                                                                                                     - HCS C7a, C7c              Services Board
                                                                                                              C7c
                                                                                                                                                                                  performance reviews                                                                                              - To co-ordinate external assessment processes
                                                                                                              C8a
                                                                                                                                                                                  - Essence of Care audits                                                                                         (Healthcare Standards, NHSLA, ALE) and collation of
                                                                                                              C12
                                                                                                                                                                                  - Reviewed governance arrangements in view of new                                                                required evidence portfolios
                                                                                                              D1
                                                                                                                                                                                  Healthcare Standards & organisational change in progress                                                         - To develop and undertake a Governance Audit within the
                                                                                                              D3
                                                                                                                                                                                                                                                                                                   PCT
                                                                                                              D4a
                                                                                                                                                                                                                                                                                                   - Devise and deliver Risk Management Training for Board
                                                                                                              D4b
                                                                                                                                                                                                                                                                                                   Members and Senior Managers


   E4              Develop an Asset Management System for the PCT            NM               Y                        E4.1           - Failure to control asset maintenance      - Planned Preventative Maintenance System                           12              #REF!       #REF!            '- Develop an asset control policy to be approved by the              6           #REF!          #REF!             - SABS Returns                                             Yes               Yes - Not
                   to cover all medical devices and equipment for the                                                  (CS)           and track hazard reports to avoid           - SLA with BHNFT re maintenance of medical devices                                                               PCT                                                                                                                HCS C4b, C1b                                                                 confirmed
                   purposes of staff and patient safety, maintenance                                                                  compromising patient safety                 - Service contracts for specialist specific equipment                                                            - Ensure acceptance testing of Asset Registers is carried                                                                                                                                       acceptance of
                   and control/security of assets                                                                                                                                 - Helpdesk fault reporting                                                                                       out                                                                                                                                                                                             asset register
                                                                                                                                                                                  - Statutory checks documentation i.e. PA Testing, Fire, Pest                                                     - Continue to update PPM system
                                                                                                                                                                                  Control                                                                                                          - Local working instructions for directly employed labour
                                                                                                                                                                                  - Policies - Medical Devices, Contractor Control Policy,                                                         (DEL)
                                                                                                                                                                                  Asbestos at Work Policy
                                                                                                              C1b                                                                 - Community Equipment asset system for equipment now in
                                                                                                              C4b                                                                 operation
                                                                                                              D1                                                                  - Recruited a specialist estates officer to control assets &
                                                                                                                                                                                  develop procedures
                                                                                                                                                                                  - Developed asset database via the Facilities Management
                                                                                                                                                                                  software
                                                                                                                                                                                  - Ensured collection of asset details across the PCT
                                                                                                                                                                                  - New Asset Register
                                                                                                                                                                                  - Developed asset database via the Planet FM Software
                                                                                                                                                                                  - Ensure collection of asset details across the PCT


 Fa1               Ensure current facilities meet the national guidance NM                    Y                       Fa1.1           - Health & Safety of patients, staff,       - Waste policy                                                      12              #REF!       #REF!            - Waste Policy reviewed following publications of                     8           #REF!          #REF!             - June 2007                 - Internal ad hoc waste audit - No               Yes - Estate
                   & legislation & all new facilities are designed to                                                 (CS)            public & wider environment is placed at     - Commercial Manager is nominated waste lead                                                                     Hazardous Waste Regulations                                                                                        Transportation of           Sharps Audit                                     Audit Report in
                   promote effective care & optimise health outcomes                                                                  risk through unsafe practices in relation   - Contract for off site waste disposal                                                                           - Safe Management of Healthcare Waste (Purple Book)                                                                dangerous goods safety                                                       draft due Jan
                                                                                                                                      to the handling of waste                    - Consent for discharge for foul sewer                                                                           - Updating the specifications for the collection & disposal of                                                     audit report on behalf of                                                    2008
                                                                                                                                                                                  - Waste survey & audit undertaken by independent consultant                                                      waste contracts (management)                                                                                       BPCT (included waste)
                                                                                                                                                                                  -Produce an annual board report on the main kitchen                                                              - To implement recommendations from Waste Survey Audit                                                             - HCS C4e
                                                                                                                                                                                  inspections and ensure a monitoring programme is in place, in                                                    - Approval gained to appoint a Waste Manager
                                                                                                                                                                                  accordance with current Environmental Health legislation                                                         - Assess impact of HTM 07/01 - Safe Management of
                                                                                                                                                                                  - PEAT inspections are carried out and reported to the Care                                                      Health Care Waste
                                                                                                              C4e                                                                 Services Board                                                                                                   -Ensure regular monitoring and reporting against the plan
                                                                                                              C15a                                                                - Produce and annual catering report to ensure the six criteria                                                  - PEAT inspections due Feb/March 08
                                                                                                              C15b                                                                for Better Hospital Food Programme are in place, and ensure a                                                    - Produce a Trust Food Waste Policy, and ensure that an
                                                                                                                                                                                  programme is in place to monitor the standards                                                                   annual report is produced for the board
                                                                                                                                                                                  -Produce annual customer satisfaction surveys for Facilities
                                                                                                                                                                                  Services
                                                                                                                                                                                  - Produce a strategic cleaning plan




   E5              Ensure current facilities meet the national guidance      NM               Y                        E5.2           - The PCTs estate is inappropriate to       - Estates Strategy 2006                                             12              #REF!       #REF!            - Review current Estates Strategy in line with agreed                 8           #REF!          #REF!             - Barnsley LIFT CO          - Minutes of Strategic         No                No
                   and legislation, and all new facilities are designed to                                             (CS)           meet the requirements/demands of            - Older Peoples Service reprovision project (Resource                                                            business plan                                                                                                      - BMBC Scrutiny             Partnering Board to PCT
                   promote effective care and optimise health                                                                         provided services and business              Centres)                                                                                                         - Propose revised strategy to service Reprovision Board                                                            Committee on LIFT &         Board
                   outcomes                                                                                                           development                                 - Strategic Service Development Plans (SSDP)                                                                     and Commissioning OMG                                                                                              new MH Unit
                                                                                                                                                                                  - Lease agreements                                                                                               - Consultation with Staff side/SHA and key stakeholders                                                            - ERIC Returns
                                                                                                              C20a                                                                - NHS LIFT - Traunche 1a                                                                                         - Implement accommodation register on all PCT premises
                                                                                                              C20b                                                                - GP based developments                                                                                          - Produce business unit occupation reports
                                                                                                              C21                                                                 - PCT/ BMBC License agreement for Locality Centres
                                                                                                              D12a                                                                - Capital Programme new 5 Year Estates Strategy (part of
                                                                                                              D12b                                                                Estates Strategy)
                                                                                                                                                                                  - NHS lift traunche 2 (Cudworth and Grimethorpe)
                                                                                                                                                                                  - SLA with BHNFT
                                                                                                                                                                                  - Designed all new premises and refurbishments in
                                                                                                                                                                                  collaboration with infection control and Health and Safety


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Objective Number




                                                                                         Care Services
 Business Unit




                                                                         Lead Director




                                                                                                                    Risk Number




                                                                                                                                                                                                                                                                                             Traffic Light




                                                                                                                                                                                                                                                                                                                                                                                                             Traffic Light
                                                                                                                                                                                                                                                                Risk Rating




                                                                                                                                                                                                                                                                                                                                                                              Risk Rating
                                                                                                         Mapped                                                                                                                                                                                                                                                                             Residual Risk                     Assurance - External        Internal Management                                Gaps in
                              DIRECTORATE OBJECTIVE                                                                                                  RISK                                                Existing Controls                                                    Risk Rating                                         Planned Controls                                                                                                                                   Gaps In Control
                                                                                                         to HCS                                                                                                                                                                                                                                                                                Rating                          (inc Internal Audit)            Assurance                                    Assurance



   E2              Ensure that the Care Services and Commissioner        NM               Y                       E2.2            - The PCTs Estates Strategy is              - Estates Strategy 2006                                                           12              #REF!       #REF!            - Review current Estates Strategy in line with agreed                 8           #REF!        #REF!            - Barnsley LIFT CO       - Minutes of Strategic         No                No
                   arm of the PCT have a robust Estates Strategy to                                               (CS)            inappropriate to meet the                   - Older Peoples Service reprovision project (Resource                                                                          business plan                                                                                                   - BMBC Scrutiny          Partnering Board to PCT
                   meet their requirements                                                                                        requirements/demands of provided            Centres)                                                                                                                       - Propose revised strategy to service Reprovision Board                                                         Committee on LIFT &      Board
                                                                                                                                  services and business development           - Strategic Service Development Plans (SSDP)                                                                                   and Commissioning OMG                                                                                           new MH Unit
                                                                                                                                                                              - Lease agreements                                                                                                             - Consultation with Staff side/SHA and key stakeholders                                                         - ERIC Returns
                                                                                                                                                                              - NHS LIFT - Traunche 1a                                                                                                       - Implement accommodation register on all PCT premises
                                                                                                          C20a                                                                - GP based developments                                                                                                        - Produce business unit occupation reports
                                                                                                          C20b                                                                - PCT/ BMBC License agreement for Locality Centres
                                                                                                          C21                                                                 - Capital Programme new 5 Year Estates Strategy (part of
                                                                                                          D12a                                                                Estates Strategy)
                                                                                                          D12b                                                                - NHS lift traunche 2 (Cudworth and Grimethorpe)
                                                                                                                                                                              - SLA with BHNFT
                                                                                                                                                                              - Designed all new premises and refurbishments in
                                                                                                                                                                              collaboration with infection control and Health and Safety



   P4              Support the business units in the development of      MK               Y                       P4.1            Poorly equipped staff leading to a risk of - Mandatory training                                                               12              #REF!       #REF!                                                                                  8           #REF!        #REF!            HCS C11a, C11c           - Mandatory training targets   No                No
                   responsive and meaningful workforce planning.                                                  (CS)            compromised patient safety and lack of - Personnel Development Plans                                                                                                                                                                                                                                                - HCS C11b
                                                                                                                                  Business Development                       - KSF
                                                                                                                                                                             - Workforce plan
                                                                                                                                                                             - Ensured staff training needs are clearly identified through the
                                                                                                                                                                             PDP process.
                                                                                                                                                                             - Ensured that all Mandatory training targets are met.
                                                                                                          C10a                                                               - Ensured staff Development reviews and KSF processes are
                                                                                                          C10b                                                               effectively implemented
                                                                                                          C11a                                                               - Supported the implementation of the Mandatory record
                                                                                                          C11b                                                               keeping training across all business units
                                                                                                          C11c                                                               - Supported the delivery of the adult protection training across
                                                                                                                                                                             all business units.
                                                                                                                                                                             - Supported the business units in Workforce planning activities




   P3              Support the delivery of quality services that meet MK                  Y                       P3.1            - Risk of compromised patient safety        - Existing Clinical Governance arrangements with :                                12              #REF!       #REF!            - Review current clinical supervision practice and make               8           #REF!        #REF!            HCS - C07a, C07c         - Board approval of new        No                No
                   national and local priorities, ensuring targets are                                            (CS)            leading to a Risk of potential litigation      - Clinical Governance lead                                                                                                  recommendations to achieve minimum standards                                                                                             arrangements
                                                                                                                                                                                 - Clinical Governance Sub Committee and other Committee structures
                   achieved.                                                                                                      and complaints                              reporting to it
                                                                                                                                                                              - Reconfigured Governance arrangements in the PCT
                                                                                                                                                                              - Led the work on developing robust structure for integrated Clinical
                                                                                                                                                                              Governance/ Clinical with the provider arm of the PCT.
                                                                                                                                                                              - developed a managed approach - timeline to implement the new
                                                                                                                                                                              arrangement
                                                                                                                                                                              - Reviewed progress of revised arrangements.
                                                                                                                                                                              - Ensured effective risk management and control measures are in place
                                                                                                                                                                              within all of the business units.
                                                                                                                                                                              - Reviewed the clinical governance structure and make recommendations for
                                                                                                                                                                              change.
                                                                                                                                                                              - Provided strong clinical leadership and clinical engagement to all of the
                                                                                                          C7a                                                                 business units.
                                                                                                          C7c                                                                 - Participated in the annual audit cycle in order to monitor standard/provision
                                                                                                                                                                              of care
                                                                                                                                                                              - Reviewed and update raising the standards document PCT record keeping
                                                                                                                                                                              standards.
                                                                                                                                                                              - Led the role out of the essence of care benchmarking topics across all
                                                                                                                                                                              business units.
                                                                                                                                                                              - Implemented ‘dignity workbook’ with all practitioners within inpatient areas.
                                                                                                                                                                              - Developed new website for essence of care.
                                                                                                                                                                              - Developed infrastructure to support the Controlled Drugs Accountable
                                                                                                                                                                              officer role
                                                                                                                                                                              - Continue to monitor progress by infection control team against
                                                                                                                                                                               work programme and associated action plans.
                                                                                                                                                                              - Monitored progress by infection control team against work programme and
                                                                                                                                                                              associated action plans.



   P1              Support the development of the new Business Units     MK               Y                       P1.1            - Inappropriate professional practice       - Professional Accountability arrangements                                        12              #REF!       #REF!            - Led the actioning of the CNO review in Mental Health.               8           #REF!        #REF!            HCS - C01a, C07a, C07c Professional Forum report to     No                No
                   to enable them to operate as a stand alone Business                                            (CS)            which could lead to compromised             - Professional codes of conduct/practice                                                                                                                                                                                                                              Provider & Commissioner
                                                                                                                                  Patient care                                - Directorate development programme produced with Lead                                                                                                                                                                                                                Governance Committees
                                                                                                                                                                              professionals & key managers                                                                                                                                                                                                                                          - PEC
                                                                                                                                                                              - Reviewed Lead professional roles with Lead professionals &                                                                                                                                                                                                          - HCS C5b, C10b
                                                                                                                                                                              Line Managers reviewed
                                                                                                                                                                              - Agreed & implement working together prinicples with both
                                                                                                                                                                              Lead professioanls & Line managers
                                                                                                          C5a                                                                 - Reviewed progress of Directorate development programme
                                                                                                          C5b                                                                 (at end of year)
                                                                                                          C5c                                                                 -Reviewed the lead professional roles and develop a strong
                                                                                                          C8a                                                                 professional lead to ensure effective clinical engagement
                                                                                                          C10b                                                                within all of the business units
                                                                                                          C11                                                                 -Provided clinical support to business unit managers as they
                                                                                                          D4c                                                                 explore business opportunities and organisational growth
                                                                                                                                                                              -Performance managed the Infection control team to ensure
                                                                                                                                                                              the Health Act requirements are met




OD2                Ensure financial viability of the Operational Business KT              Y                       OD2.2 - Substance Misuse Unit is not                        - Budget Control & cost basis control                                             12              #REF!       #REF!            - Ensure financial robustness of the Substance Misuse                 8           #REF!        #REF!                                                                    No                Yes
                   Units                                                                                           (CS) financially viable under present                                                                                                                                                     Inpatient Unit by delivering high quality care which is sought
                                                                                                                        commissioning arrangements &                                                                                                                                                         by wider Drug Action team Commissioners
                                                                                                                        becomes a cost pressure to the PCT                                                                                                                                                   - Invoke the Risk Management Protocol of the Joint Agency
                                                                                                                                                                                                                                                                                                             Group
                                                                                                          C7d
                                                                                                                                                                                                                                                                                                             - Submission of a proposal to the National Treatment
                                                                                                                                                                                                                                                                                                             Agency to expand provision of treatment in inpatient care
                                                                                                                                                                                                                                                                                                             beyond Barnsley




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Objective Number




                                                                                        Care Services
 Business Unit




                                                                        Lead Director




                                                                                                                   Risk Number




                                                                                                                                                                                                                                                                              Traffic Light




                                                                                                                                                                                                                                                                                                                                                                                             Traffic Light
                                                                                                                                                                                                                                              Risk Rating




                                                                                                                                                                                                                                                                                                                                                              Risk Rating
                                                                                                        Mapped                                                                                                                                                                                                                                                              Residual Risk                     Assurance - External          Internal Management                                   Gaps in
                              DIRECTORATE OBJECTIVE                                                                                               RISK                                           Existing Controls                                          Risk Rating                                            Planned Controls                                                                                                                                     Gaps In Control
                                                                                                        to HCS                                                                                                                                                                                                                                                                 Rating                          (inc Internal Audit)              Assurance                                       Assurance



OD3                Ensure that the Operational Business Units deliver   KT               Y                       OD3.1 Compromise Patient Safety and quality             - NICE Groups                                                        12              #REF!         #REF!             - Implement appropriate risk management and control                  8           #REF!        #REF!            - Patient Satisfaction     - Patient Satisfaction Survey   No                  No
                   quality services that meet national and local                                                  (CS) of care which will result in non                  - Clients Boards                                                                                                     measures including complaints/Significant Events/IR1                                                           Survey See CSCI            - HCS C7f
                   priorities, ensuring that targets are achieved                                                      achievement of national and local                 - SLA meetings                                                                                                       incidents – ensure all incidents are reported immediately                                                      Inspections
                                                                                                                       targets by the Operational Business               - Health Care Standards                                                                                              and that the incident learning is shared at the earliest
                                                                                                                       Units                                             - Local Clinical Governance Groups                                                                                   opportunity
                                                                                                                                                                                                                                                                                              - Ensure business unit meetings are utilised appropriately to
                                                                                                         C1                                                                                                                                                                                   plan and implement systems to plan and manage the
                                                                                                         C4                                                                                                                                                                                   quality of service provision
                                                                                                         C5                                                                                                                                                                                   - To implement, complete, comply with and monitor
                                                                                                         C6                                                                                                                                                                                   adherence to the PCT Provider Quality Framework
                                                                                                         C7                                                                                                                                                                                   - Ensure ongoing service congruence with, and optimise
                                                                                                         C13                                                                                                                                                                                  business opportunities arising from Every Adult Matters
                                                                                                                                                                                                                                                                                              policy directives
                                                                                                                                                                                                                                                                                              - Proactively support the introduction of individual budgets
                                                                                                                                                                                                                                                                                              and self directed support




OD3                Ensure that the Operational Business Units deliver   KT               Y                       OD3.1 Compromise Patient Safety and quality             - NICE Groups                                                        12              #REF!         #REF!             - Implement appropriate risk management and control                  8           #REF!        #REF!            - Patient Satisfaction     - Patient Satisfaction Survey No                    No
                   quality services that meet national and local                                                  (CS) of care which will result in non                  - Clients Boards                                                                                                     measures including complaints/Significant Events/IR1                                                           Survey See CSCI            - Commissioner Clinical Audit
                   priorities, ensuring that targets are achieved                                                      achievement of national and local                 - SLA meetings                                                                                                       incidents – ensure all incidents are reported immediately                                                      Inspections                Schedule and reports to
                                                                                                                       targets by the Operational Business               - Health Care Standards                                                                                              and that the incident learning is shared at the earliest                                                       - HCS C7a, C7c             Commissioner Governance
                                                                                                                       Units                                             - Local Clinical Governance Groups                                                                                   opportunity                                                                                                                               Committee
                                                                                                                                                                                                                                                                                              - Ensure business unit meetings are utilised appropriately to                                                                             - HCS C7f
                                                                                                         C1                                                                                                                                                                                   plan and implement systems to plan and manage the
                                                                                                         C4                                                                                                                                                                                   quality of service provision
                                                                                                         C5                                                                                                                                                                                   - To implement, complete, comply with and monitor
                                                                                                         C6                                                                                                                                                                                   adherence to the PCT Care Services Quality Framework
                                                                                                         C7                                                                                                                                                                                   - Ensure ongoing service congruence with, and optimise
                                                                                                         C13                                                                                                                                                                                  business opportunities arising from Every Adult Matters
                                                                                                                                                                                                                                                                                              policy directives
                                                                                                                                                                                                                                                                                              - Proactively support the introduction of individual budgets
                                                                                                                                                                                                                                                                                              and self directed support



HR7                To ensure the PCT meets its Health and Safety        GM               Y                       HR7.2 Failing to meet the requirements of the           - Fire Safety Advisor in post                                        12              #REF!         #REF!             - to agree a fire safety policy for the PCT which reflects           8           #REF!        #REF!            - Fire Brigade inspections - Fire risk assessment for      Yes - Identification - No
                   obligations and priorities.                                                                    (CS) regulatory Reform (fire Safety) Order to          - Fire Policy                                                                                                        recent changes in legislation                                                                                  (Held by H & S             each premises                   of responsible
                                                                                                                       effectively, manage our fire safety               - Reviewed Health and Safety Training within PCT                                                                     - Identify responsible Manager for each PCT premises                                                           department)                - Monitoring of actions         managers at each
                                                                                                                       arrangements                                      - Awareness of the regulatory Fire reform order to provider                                                          - to implement new health and safety Training                                                                  - HSE inspections                                          PCT premises
                                                                                                                                                                         governance committee and Health & Safety Committee                                                                                                                                                                                  - HCS C20a                                                 also Fire
                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Wardens,
                                                                                                                                                                         - Joint working between Health & Safety and the Estates
                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Marshalls.
                                                                                                                                                                         Department
                                                                                                                                                                                                                                                                                                                                                                                                                                                                        - Sufficient
                                                                                                                                                                         - Risk assessments been completed on all PCT buildings with                                                                                                                                                                                                                                    inspection records,
                                                                                                                                                                         appropriate action plans in place for upgrades/alterations                                                                                                                                                                                                                                     maintenance and
                                                                                                                                                                         - Established training of competent persons package                                                                                                                                                                                                                                            testing
                                                                                                                                                                                                                                                                                                                                                                                                                                                                        - Issues with Fire
                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Risk Assessment
                                                                                                        C20a,                                                                                                                                                                                                                                                                                                                                                           within buildings
                                                                                                        D12b,                                                                                                                                                                                                                                                                                                                                                           exempt from fire
                                                                                                         D1                                                                                                                                                                                                                                                                                                                                                             certification
                                                                                                                                                                                                                                                                                                                                                                                                                                                                        (CLASP buildings)
                                                                                                                                                                                                                                                                                                                                                                                                                                                                        ie Mount Vernon
                                                                                                                                                                                                                                                                                                                                                                                                                                                                        - Operational fire
                                                                                                                                                                                                                                                                                                                                                                                                                                                                        safety
                                                                                                                                                                                                                                                                                                                                                                                                                                                                        arrangements with
                                                                                                                                                                                                                                                                                                                                                                                                                                                                        the BMO




  Fi4              To respond to the business requirements of PCT SH                     Y                       Fi4.2           Failure to integrate high and medium    - Timetable of required activity agreed                              12              #REF!         #REF!             - To relocate existing services from York and North             12               #REF!        #REF!                                                                       Yes - The           Yes - No
                   Commissioners and Providers by influencing and                                                (CS)            secure Mental Health Commissioning                                                                                                                           Yorkshire PCT to Norcom                                                                                                                                                   existing function   assurance, as
                   supporting areas of development                                                                               Team within PCT                                                                                                                                                                                                                                                                                                                        is not yet          function not yet
                                                                                                         C7d                                                                                                                                                                                                                                                                                                                                                            operational         operational within
                                                                                                         C7f                                                                                                                                                                                                                                                                                                                                                            within PCT          PCT




  SI1              Deliver the service change/development outcomes SR                    Y                       SI1.1           Not achieving service competitiveness - Secure income for Hydrotherapy service provided to BHNFT                  8 Medium Risk          Green               - Diversity Strategy Action Plan                                     3           #REF!        #REF!            - HCS C18                  - HCS C19                       Yes                 Yes
                   across agreed priority areas as set out in the                                                (CS)            increase waiting times and impact on - Negotiated revised MSK service contract with PCT                                                                      - Race Equality action plan                                                                                                               - Contract GP monitoring
                   Business Development Project Register                                                                         service provision                     Commissioner based on agreement of local tariff                                                                        - Develop a clinical management system                                                                                                    - Prune two project reviews
                                                                                                                                                                       - Agreed and implemented revised MSK services specification                                                            - Development of business links                                                                                                           with in built assurances
                                                                                                                                                                       from October 07                                                                                                        - Progress all projects contained within the Business                                                                                     - No delays programme
                                                                                                                                                                       -Completed option appraisal for expansion of inpatient                                                                 Development/Business register                                                                                                             monitoring
                                                                                                                                                                       substance misuse services                                                                                                                                                                                                                                        - Review of care pathways.
                                                                                                                                                                       -Initiated work programme and action plan for Improving
                                                                                                                                                                       Access to Psychological Therapies
                                                                                                         C18                                                           -Negotiated additional business through MSK service
                                                                                                         D11a                                                          development proposals with PCT Commissioner
                                                                                                         D11b                                                          Negotiated additional business through Podiatric Surgery
                                                                                                         D11c                                                          business development proposal.
                                                                                                         D11d                                                          -Negotiated additional business through Frail Elderly business
                                                                                                                                                                       development proposal
                                                                                                                                                                       - Negotiated additional business through Community
                                                                                                                                                                       Continence & Urology Service proposal for women under 65.
                                                                                                                                                                       -Sexual Health & Family Planning Service Review &
                                                                                                                                                                       Development Plan




  IS6              Improve data capture and quality within Care SH                       Y                       IS6.2           - Organisation unable to provide        - Reporting of gaps identified in activity reporting (HI Unit)            8          #REF!         #REF!             - Implementation of Data Warehouse approach to                       4           #REF!        #REF!            - External Audit 2006/07   - Provide Information Reports No                    No
                   Services                                                                                       (CS)           information to support key business     - data Quality Audit Report produced Monthly                                                                         information provision                                                                                          ref 4 IT Disaster          to Provider Directors
                                                                                                                                 requirements, especially activity                                                                                                                            - Develop PCT data quality policy                                                                              Recovery Plan              - Data Quality audit report
                                                                                                         D6                      recording                                                                                                                                                    - Engage with service managers and agree recording                                                                                        produced Monthly
                                                                                                                                                                                                                                                                                              protocols for identified Business Units




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Objective Number




                                                                                       Care Services
 Business Unit




                                                                       Lead Director




                                                                                                                  Risk Number




                                                                                                                                                                                                                                                                                       Traffic Light




                                                                                                                                                                                                                                                                                                                                                                                                          Traffic Light
                                                                                                                                                                                                                                                          Risk Rating




                                                                                                                                                                                                                                                                                                                                                                           Risk Rating
                                                                                                       Mapped                                                                                                                                                                                                                                                                            Residual Risk                     Assurance - External          Internal Management                                   Gaps in
                              DIRECTORATE OBJECTIVE                                                                                              RISK                                                Existing Controls                                                  Risk Rating                                          Planned Controls                                                                                                                                          Gaps In Control
                                                                                                       to HCS                                                                                                                                                                                                                                                                               Rating                          (inc Internal Audit)              Assurance                                       Assurance



  IS1              Planning and implementation of improvement to the   SH               Y                       IS1.2           Business has no process to log and        - Service Level Agreed for contracted IT support                                     8          #REF!       #REF!            - Refine catalogue of provided information services (word,               4           #REF!        #REF!            - External Audit report                                      No                No
                   day to day support for PCT information systems                                                (CS)           manage a programme of development         - Monitoring & analysis of Help Desk calls (more proactive)                                                                  excel, etc)                                                                                                        06/07 4 IT Disaster
                                                                                                                                items and therefore requirements cannot   - Appointment of Deputy Director of IS - focus on delivery of                                                                                                                                                                                   recovery
                                                                                                                                be met                                    operational work
                                                                                                                                                                          - Implemented an IT SLA management framework
                                                                                                        C13c                                                              - Implemented the information services work programme
                                                                                                         D6                                                               procedure
                                                                                                                                                                          - Infrastructure project - Developed strategy for linking staff on
                                                                                                                                                                          BMBC sites to PCT network - Agreed 1/11/07



  IS4              To develop the use of information systems In SH                      Y                       IS4.1           - Lack of integration of IT systems to    - Information systems in use                                                         8          #REF!       #REF!            - Secure income for Hydrotherapy service provided to BHNFT               8           #REF!        #REF!            Prior to roll out:         Prior to roll out:                Yes                Yes
                   Primary Care                                                                                  (CS)           improve information sharing & support     - Choose & Book                                                                                                              -Complete option appraisal for expansion of inpatient substance                                                    - Connecting for Health    - PCT comprehensive testing       - No integration - No audits taken
                                                                                                                                clinical care across PCT Provider         - PAS                                                                                                                        misuse services                                                                                                    - Expert Reference         prior to roll out                 - No capability to place
                                                                                                                                Services & Referes                        - Community system                                                                                                           -Initiate work programme and action plan for Improving Access to                                                   Group (for design &        - Reports to Provider Directors   integrate at
                                                                                                                                                                          - Ad hoc individual client specific requests to PCT                                                                          Psychological Therapies                                                                                            specifications)            - Reports to Project Boards       present without
                                                                                                                                                                                                                                                                                                       -Negotiate additional business through MSK service development
                                                                                                                                                                          services/GPs (Commissioner/Provider team support this)                                                                                                                                                                                          - Strategic Health         - Approved project will be        significant local
                                                                                                                                                                                                                                                                                                       proposals with PCT Commissioner
                                                                                                                                                                          - Confidentiality policy                                                                                                                                                                                                                        Authority                  subject to YaTH SHA               investment
                                                                                                                                                                                                                                                                                                       -Agree and implement revised MSK services specification from
                                                                                                                                                                          - Robust clinical practice                                                                                                   October 2007                                                                                                                                  Performance Monitoring
                                                                                                                                                                          - Regular reports to NPFIT & PCT Boards                                                                                      -Negotiate additional business through Podiatric Surgery business
                                                                                                                                                                          - GP Practice systems EMIS/InpS offer limited integrated with                                                                development proposal.
                                                                                                                                                                          NPFIT (C&B, GP to GP, Prescribing)                                                                                           -Negotiate additional business through Frail Elderly business
                                                                                                                                                                          - Received IM&T DES plans from each practice                                                                                 development proposal
                                                                                                                                                                                                                                                                                                       - Negotiate additional business through Community Continence &
                                                                                                        D6                                                                                                                                                                                             Urology Service proposal for women under 65.
                                                                                                                                                                                                                                                                                                       -Sexual Health & Family Planning Service Review & Development
                                                                                                                                                                                                                                                                                                       Plan
                                                                                                                                                                                                                                                                                                       - Diversity Strategy Action Plan
                                                                                                                                                                                                                                                                                                       - Race Equality action plan
                                                                                                                                                                                                                                                                                                       - Develop a clinical management system
                                                                                                                                                                                                                                                                                                       - Development of business links
                                                                                                                                                                                                                                                                                                       - Progress all projects contained within the Business
                                                                                                                                                                                                                                                                                                       Development/Business register
                                                                                                                                                                                                                                                                                                       - PCT MPfit Process Board has been expanded to include BMBC
                                                                                                                                                                                                                                                                                                       and BHNFT
                                                                                                                                                                                                                                                                                                       - Care Services information systems replacement programme
                                                                                                                                                                                                                                                                                                       - SHA accepted plan IM&T which maps out integration of systems


PQ 5               Develop a systematic PCT wide approach to           SB               Y                       PQ 5.1 - PCT not achieving its legal/statutory            - PPI Steering Group and Sub Groups                                                  8          #REF!       #REF!            - Raise awareness of PPI/Patient Experience both with staff              4           #REF!        #REF!            - National                 - 1/4ly report on PPI to Care   No                  No
                   PPI/Patient Experience and implement within Care                                              (CS) duty to involve and consult with patients           - Links with Barnsley Participation Proces                                                                                   and the wider public using various methods i.e. local                                                              acknowledgement for PPI    Services Board
                                                                                                                                                                          - Local award to celebrate Patient & Public Involvement innovation
                   Services to ensure compliance with the Health &                                                     and the public resulting in services not           - PPI Toolkit
                                                                                                                                                                                                                                                                                                       newsletters, intranet, internet, advertising, etc                                                                  tool kit                   - Non-Executive member
                   Social Care Act, 2001                                                                               being responsive to local need & what              - Local complaints Leaflet                                                                                                   - Ensure that the PCT meets all its national and local                                                             - HCS C16                  involved in the work if the PPI
                                                                                                                       people want                                        - National Patient Surveys Mental Health & Primary Care                                                                      targets in relation to PPI/Patient Experience.                                                                                                Steering Group
                                                                                                                                                                          - PPI Training for Staff                                                                                                     - Establish a Patient Experience Group with support from                                                                                      - HCS C17
                                                                                                                                                                          - Local compact of statutory/voluntary & community sector organisations                                                      Care Services and the Barnsley Participation Process
                                                                                                                                                                          - Developed links with PCTs PPI forum
                                                                                                                                                                          - Links with Overview & Scrutiny Committee
                                                                                                                                                                          - PPI Newsletter
                                                                                                                                                                          - PPI Strategy
                                                                                                                                                                          - Communications Strategy
                                                                                                                                                                          - Consultation Protocol
                                                                                                        C16                                                               - SHA Stocktake in April 2006 on PALS/PPI
                                                                                                        C17                                                               - Guidance for the production & procedure for approval of patient & public
                                                                                                         D8                                                               information
                                                                                                                                                                          - Collection & reporting of patient compliments via Complaints Manager
                                                                                                        D11a                                                              - Continued to develop the tools and processes to support staff in
                                                                                                                                                                          undertaking PPI activities and using patients intelligence to improve local
                                                                                                                                                                          services ensuring they are responsive to people’s needs
                                                                                                                                                                          - Undertaken a PPI Baseline Assessment to establish the current
                                                                                                                                                                          arrangements and gaps in relation to PPI and the use of patient intelligence.
                                                                                                                                                                          - Used the information gained from the PPI Baseline Assessment to manage
                                                                                                                                                                          the gaps and make recommendations for change across the PCT
                                                                                                                                                                          - Established links and processes to gather information from Care Services,
                                                                                                                                                                          and feed into Patient Experience Report to the Care Services Board
                                                                                                                                                                          - Produced the Care Services Patient Experience Report in the agreed
                                                                                                                                                                          format
                                                                                                                                                                          - Produced the PCT’s statutory patient publications ie Patient Prospectus
                                                                                                                                                                          and Annual Report through consultation with stakeholders, patients and the
                                                                                                                                                                          public.
                                                                                                                                                                          - Updated in line with national guidance the PCT’s PPI staff toolkit and re-
PQ 4               Ensure that the PCT has effective Governance        SB               Y                       PQ 4.2 - Patients, staff, visitors are harmed as a Corporate systems:                                                                          8          #REF!       #REF!            Corporate Systems:                                                       4           #REF!        #REF!            Corporate Systems:         Corporate Systems:           No                     No
                   arrangements in place to mitigate risk to the                                                 (CS) result of the PCT failing to put in place - Risk Management Strategy                                                                                                             - Revise training available for Risk Management                                                                    - Staff Survey 06/07       - Risk & NHSLA development
                   organisation in accordance with national guidance                                                   risk management systems                     - Governance Committee                                                                                                              - Implement revised incident reporting procedures                                                                  Identifying, learning &    action plans in place &
                                                                                                                                                                   - Clinical Risk Steering Group                                                                                                      - RM Dept, audits of RM/H&S manuals                                                                                improving from incidents   reported to Governance
                                                                                                                                                                   - Complaints, SUI & Claims Sub Group systems & procedures                                                                           - To coordinate external assessment processes (NHSLA,                                                              - SHA Monitoring of SUIs   Committee
                                                                                                                                                                   - Self assessment against Assurance Standards                                                                                       Healthcare Standards & Fitness for Purpose) & collation of                                                         - NPSA Monitoring of       - RM Department audits of RM
                                                                                                                                                                   - Health & Safety & Risk Assessment Policy & Procedure                                                                              required evidence portfolios                                                                                       PCT Patient Safety         /H&S Manuals
                                                                                                                                                                   Manuals                                                                                                                             - To develop & undertake Governance Audit within the PCT                                                           Incidents                  - Assurance Framework &
                                                                                                        C1a                                                        - Central Risk Management & Health & Safety                                                                                         - Review incident reporting processes                                                                              - Internal Audit report    Risk Register
                                                                                                        C1b                                                        Teams/competent advisors                                                                                                            Identifying, learning & improving from incidents:                                                                  06/07 ref 11 Risk
                                                                                                        C7a                                                        - Risk Management/H&S Training modules including induction                                                                          - Further develop trends analysis & feedback to operational                                                        Management, Ref 18         Identifying, learning &
                                                                                                        C7c                                                        - Risk & NHSLA development action plans in place                                                                                    areas                                                                                                              Assurance Framework        improving from incidents
                                                                                                        C8a                                                        - PCT Risk Register & Assurance Framework                                                                                           - To develop and implement a governance system (for                                                                - HCS C20a, C1a, C1b,      - 1/4ly reporting to
                                                                                                        C12                                                                                                                                                                                            policies and procedures) within the PCT                                                                            C7a, C7c, C4a, C4d, C4e    Governance Committee
                                                                                                        D1                                                                Identifying, learning & improving from incidents:                                                                            - To provide required statutory documents and appropriate                                                                                     against Risk Management Key
                                                                                                        D3                                                                - Incident Management & Reporting                                                                                            governance reports, for example the assurance framework,                                                                                      Indicators
                                                                                                        D4a                                                               - Risk Indicators                                                                                                            the statement on internal control and risk management                                                                                         -Minutes from Governance
                                                                                                        D4b                                                                                                                                                                                            annual reports                                                                                                                                Committee to Board
                                                                                                                                                                          Acting on & implementing safety notices/alerts/communication                                                                 - To devise and deliver Risk Management Training for                                                                                          - Complaints & SUI Sub
                                                                                                                                                                          - Safety Alerts                                                                                                              Board Members and Senior Managers                                                                                                             Group - responsible to &
                                                                                                                                                                          - SABS alert system                                                                                                                                                                                                                                                        reports to Care Services
                                                                                                                                                                                                                                                                                                                                                                                                                                                     Board
                                                                                                                                                                                                                                                                                                                                                                                                                                                     Incident reports/trends
                                                                                                                                                                                                                                                                                                                                                                                                                                                     submitted to various RM
                                                                                                                                                                                                                                                                                                                                                                                                                                                     committees
                                                                                                                                                                                                                                                                                                                                                                                                                                                     - HCS C4c
PQ 6               Improve the patient experience for those accessing SB                Y                       PQ 6.1 - The PCT fails to deliver services which          - PPI Steering Group & Sub Groups                                                    8          #REF!       #REF!            - Identify information sources and what is collected in                  8           #REF!        #REF!            - National              - 1/4ly reports on Patient      No                     No
                   service provided by the PCT                                                                   (CS) meet the needs of patients, carers & the            - Links with Barnsley Participation Process                                                                                  relation to health outcomes and feedback from patients to                                                          acknowledgement for PPI Experience to Care Services
                                                                                                                       local community through failure to seek            - PPI toolkit                                                                                                                determine how this can be used to effect change.                                                                   toolkit                 Board
                                                                                                                       & take into account their views in                 - Local complaints leaflet                                                                                                   - Develop a system to record and monitor the use of patient                                                                                - Non-Executive member
                                                                                                                       service planning & development                     - National Patient Surveys Mental Health & Primary Care                                                                      intelligence to improve services provided by the PCT                                                                                       involved in the work of the PPI
                                                                                                                                                                          - PPI training for staff                                                                                                     - Ensure participation in the National Programme of NHS                                                                                    Steering Group
                                                                                                        C14a                                                              - Local Compact of statutory/voluntary & community sector                                                                    Surveys.                                                                                                                                   - HCS C14a, C14c, C17
                                                                                                        C14c                                                              organisation                                                                                                                 - Develop the Patient Experience Report to include
                                                                                                        C16                                                               - Developed links with the PCTs PPI forum                                                                                    activities in relation to the use of patient intelligence across
                                                                                                        C17                                                               - PPI Policies & procedures                                                                                                  all business units in Care Services and identify any gaps
                                                                                                        D9a                                                               - PPI Strategy
                                                                                                        D9b                                                               Communication Strategy
                                                                                                        D11a                                                              - Consultations protocol guidance for the production &
                                                                                                                                                                          procedures for the approval of Patient and Public information
                                                                                                                                                                          - Raised the profile of the PALS Services within Primary Care
                                                                                                                                                                          Services and those provided by the PCT.



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Objective Number




                                                                                         Care Services
 Business Unit




                                                                         Lead Director




                                                                                                                   Risk Number




                                                                                                                                                                                                                                                                                          Traffic Light




                                                                                                                                                                                                                                                                                                                                                                                                    Traffic Light
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                                                                                                                                                                                                                                                                                                                                                                     Risk Rating
                                                                                                         Mapped                                                                                                                                                                                                                                                                    Residual Risk                     Assurance - External          Internal Management                                  Gaps in
                               DIRECTORATE OBJECTIVE                                                                                               RISK                                                Existing Controls                                                   Risk Rating                                        Planned Controls                                                                                                                                  Gaps In Control
                                                                                                         to HCS                                                                                                                                                                                                                                                                       Rating                          (inc Internal Audit)              Assurance                                      Assurance



 Fa1               Ensure current facilities meet the national guidance NM                Y                       Fa1.4          - Failure to meet national standards       - Staff hygiene training                                                              8          #REF!       #REF!            - Develop a strategic Cleaning Plan                             4           #REF!        #REF!            - EHO monitoring &          - Internal hygiene reports      No                No
                   & legislation & all new facilities are designed to                                             (CS)           requirements in relation to hospital food, - PEAT certificate                                                                                                            - Ensure regular monitoring & reporting against the plan                                                  reporting                   summary - annually to the
                   promote effective care & optimise health outcomes                                                             catering & food hygiene standards          - Regular hygiene monitoring                                                                                                  - Design new premises in collaboration with Infection                                                     - Pest control report       Board
                                                                                                                                                                            - Actions from Environmental Health Officer (EHO) inspection                                                                  Control & Health & Safety                                                                                 - PEAT                      - PEAT reports to the Board
                                                                                                                                                                            reports                                                                                                                       - Continued development of internal standards
                                                                                                                                                                            - Actions from pest control reports                                                                                           - Implement kitchen cleaning schedules in all areas
                                                                                                                                                                            - Internal inspections by monitoring officer                                                                                  - Maintain knowledge of upto date legislation
                                                                                                                                                                            - Implementation of purchasing procedures                                                                                     - Continue rolling programme of food hygiene training
                                                                                                                                                                            - Locality Centre premises registered with local authority                                                                    -Produce a Trust Food Waste Policy, and ensure that an
                                                                                                                                                                            registered with CSCI & Local Authority                                                                                        annual report is produced for the board
                                                                                                                                                                            - All Locality Centres have pest control contracts
                                                                                                          C4e                                                               - PEAT inspections are carried out & reported to the Care
                                                                                                          C20a                                                              Services Board
                                                                                                          C21                                                               -Produce an annual board report on the main kitchen
                                                                                                          D12b                                                              inspections and ensure a monitoring programme is in place, in
                                                                                                                                                                            accordance with current Environmental Health legislation
                                                                                                                                                                            -Produce an annual catering report to ensure the six criteria for
                                                                                                                                                                            Better Hospital Food Programme are in place, and ensure a
                                                                                                                                                                            programme is in place to monitor the standards
                                                                                                                                                                            - Produce a strategic cleaning plan
                                                                                                                                                                            -Produced annual customer satisfaction surveys for Facilities
                                                                                                                                                                            Services




   P6              Maintain and further develop partnership working to   MK               Y                       P6.1           Failure to work in partnership will lead to - PIA Board                                                                          8          #REF!       #REF!                                                                            8           #REF!        #REF!            - External audit report     - HCS C6                        No                No
                   improve the quality of services provided                                                       (CS)           compromise patient safety and reduce - Client Boards                                                                                                                                                                                                                               06/07 ref 2 - Working
                                                                                                                                 quality of care                             - PIA agreements                                                                                                                                                                                                                       together
                                                                                                                                                                             - Care Services Board                                                                                                                                                                                                                  - CSCI com for Social
                                                                                                                                                                             - Info Sharing protocol                                                                                                                                                                                                                Care inpspection
                                                                                                                                                                             - CPA                                                                                                                                                                                                                                  - PIA risk matrix
                                                                                                                                                                             - Discharge Policy
                                                                                                                                                                             - Worked in partnership with the business units to provide
                                                                                                                                                                             professional support and share good practice across all areas.
                                                                                                                                                                             - Worked closely with the Director of Adult Social Services in
                                                                                                                                                                             developing partnership working in line with Every Adult Matters
                                                                                                                                                                             - Provided strong leadership and support to the Professional
                                                                                                          C6
                                                                                                                                                                             staff employed in BMBC
                                                                                                                                                                             - Explored and develop opportunities to benchmark essence of
                                                                                                                                                                             care topics outside of the PCT.
                                                                                                                                                                             - Worked in partnership, develop an infrastructure to support
                                                                                                                                                                             the Controlled Drugs Accountable Officer Role.
                                                                                                                                                                             - Worked in partnership with the PCT business units implement
                                                                                                                                                                             the non medical prescribing strategy across all areas.
                                                                                                                                                                             - Proactively participated in partnership work by chairing the
                                                                                                                                                                             learning disability board.




   P4              Support the business units in the development of      MK               Y                       P4.2           - Children are harmed through failure to   - Safeguarding Children Training Strategy                                             8          #REF!       #REF!                                                                            8           #REF!        #REF!            - ACPC/BSCB monitor         - Action plan from              - Safeguarding No
                   responsive and meaningful workforce planning.                                                  (CS)           put in place systems which promote &       - Joint working arrangements                                                                                                                                                                                                            serious case reviews        Safeguarding Children Board     Children
                                                                                                                                                                            - Children's & Young people's Strategic Partnership & integrations with the
                                                                                                                                 safeguard the welfare of children in       Local Authority
                                                                                                                                                                                                                                                                                                                                                                                                                    actions in turn monitored   to Complaints & SUI Sub         responsibility is
                                                                                                                                 partnership with other organisations       - Provision of Mandatory Safeguarding Children Training to all employed                                                                                                                                                                 by CSCI Commission for      Group to ensure PCT action      not included in
                                                                                                                                                                            Trust staff                                                                                                                                                                                                                             Social Care Inspectorate    has been completed              commissioning
                                                                                                                                                                            - The Health Safeguarding children forum                                                                                                                                                                                                - JAR Inspection 'Be        - Audits undertaken by Child    contracts
                                                                                                                                                                            - Child Protection professional links (Mental Health)                                                                                                                                                                                   Safe'                       protection on performance       - No formal
                                                                                                                                                                            - Designated child protection Nurse
                                                                                                                                                                            - Barnsley Safeguarding Children Board                                                                                                                                                                                                  - HCS C2                    against expected outcomes.      arrangements for
                                                                                                                                                                            - ACPC/BSCB Procedures                                                                                                                                                                                                                                              - Children's Plan Performance   the provision of
                                                                                                                                                                            - Child Protection supervision via Supervision agreement                                                                                                                                                                                                            Monitoring                      Child Protection
                                                                                                                                                                            '- Appointed a named professional in Mental Health (Business case to be                                                                                                                                                                                                                             medicals for
                                                                                                                                                                            produced) for safeguarding children                                                                                                                                                                                                                                                                 young people 16
                                                                                                                                                                            - Business case underway to fund the existing named safeguarding children
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                to 18 year olds
                                                                                                          C2                                                                doctor(s) for Primary Care & Mental Health
                                                                                                                                                                            - Ongoing development of audit
                                                                                                                                                                            - Maintained & further develop systems to promote & safeguard children's
                                                                                                                                                                            welfare
                                                                                                                                                                            - Ensured staff training needs are clearly identified through the PDP process.
                                                                                                                                                                            - Ensured that all mandatory training targets are met.
                                                                                                                                                                            - Ensured Staff development reviews and KSF processes are effectively
                                                                                                                                                                            implemented
                                                                                                                                                                            - Supported the implementation of the mandatory record keeping training
                                                                                                                                                                            across all business units
                                                                                                                                                                            - Supported the delivery of the child protection training across all business
                                                                                                                                                                            units
                                                                                                                                                                            - Supported the delivery of the adult protection training across all business
                                                                                                                                                                            units.
                                                                                                                                                                            - Supported the business units in workforce planning activities



   P3              Support the delivery of quality services that meet    MK               Y                       P3.3           Complaints/litigation arising from failure - Consened to Treatment Policy & paperwork (conforms to NHS best                      8          #REF!       #REF!            - Review current clinical supervision practice and make         8           #REF!        #REF!            - HCS C13b                  - Consent to Treatment Audit No                   No
                   national and local priorities, ensuring targets are                                            (CS)           to obtain valid consent to treatment       practice) for all service users (recognised as good practice)                                                                 recommendations to achieve minimum standards.                                                                                         undertaken (by clinical audit)
                   achieved.                                                                                                                                                - Complaints SUI & Claims Sub Group identifies area of poor                                                                                                                                                                                                         - All complaints/claims
                                                                                                                                                                            practice & trends & ensures change occurs                                                                                                                                                                                                                           monitored by Complaints, SUI
                                                                                                                                                                            - Systems in place to deal with poor performance of individuals                                                                                                                                                                                                     & Claims Sub Group
                                                                                                                                                                            '- Training
                                                                                                                                                                                                                                                                                                                                                                                                                                                - 1/4ly reports from
                                                                                                                                                                            - Staff consent workbook
                                                                                                                                                                                                                                                                                                                                                                                                                                                Complaints, SUI & Claims
                                                                                                                                                                            - Ensured effective risk management and control measures are in
                                                                                                                                                                            place within all of the business units.                                                                                                                                                                                                                             Sub Group to the Provider
                                                                                                                                                                            - Reviewed the clinical governance structure and make                                                                                                                                                                                                               Governance Committee
                                                                                                                                                                            recommendations for change.                                                                                                                                                                                                                                         - 1/4ly report to the Board from
                                                                                                          C13a                                                              - Provided strong clinical leadership and clinical engagement to all of                                                                                                                                                                                             Primary Care Reference
                                                                                                          C13b                                                              the business units.                                                                                                                                                                                                                                                 Committee
                                                                                                          C20a                                                              - Participated in the annual audit cycle in order to monitor                                                                                                                                                                                                        - HCS C20b
                                                                                                          C20b                                                              standard/provision of care
                                                                                                          C21                                                               - Reviewed and update raising the standards document PCT record
                                                                                                          D12a                                                              keeping standards.
                                                                                                          D12b                                                              - Led the role out of the essence of care benchmarking topics across
                                                                                                                                                                            all business units.
                                                                                                                                                                            - Implemented ‘dignity workbook’ with all practitioners within inpatient
                                                                                                                                                                            areas.
                                                                                                                                                                            - Developed new website for essence of care.
                                                                                                                                                                            - Monitored progress by infection control team against work
                                                                                                                                                                            programme and associated action plans.
                                                                                                                                                                            - Developed infrastructure to support the Controlled Drugs
                                                                                                                                                                            Accountable officer role




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                                                                                                                                                                                                                                              CARE SERVICES ASSURANCE FRAMEWORK




Objective Number




                                                                                         Care Services
 Business Unit




                                                                         Lead Director




                                                                                                                    Risk Number




                                                                                                                                                                                                                                                                                                     Traffic Light




                                                                                                                                                                                                                                                                                                                                                                                                               Traffic Light
                                                                                                                                                                                                                                                                        Risk Rating




                                                                                                                                                                                                                                                                                                                                                                                Risk Rating
                                                                                                         Mapped                                                                                                                                                                                                                                                                               Residual Risk                     Assurance - External             Internal Management                                  Gaps in
                              DIRECTORATE OBJECTIVE                                                                                                 RISK                                                    Existing Controls                                                         Risk Rating                                         Planned Controls                                                                                                                                    Gaps In Control
                                                                                                         to HCS                                                                                                                                                                                                                                                                                  Rating                          (inc Internal Audit)                 Assurance                                      Assurance



   P5              To engage representative service users in service     MK               Y                       P5.1            - Poor patient experience and failure to   - Essence of Care (EoC) benchmarking process (10 benchmarks)                                    8          #REF!       #REF!                                                                            4           #REF!        #REF!            - Staff & Service user        - Progress monitored by     No                     No
                                                                                                                                                                             - Training provided to staff on continuous basis
                   delivery and service monitoring in order to ensure                                             (CS)            improve quality of services                - EoC Group in service areas
                                                                                                                                                                                                                                                                                                                                                                                                                               Survey (2006) results         Governance Committee
                   equitable and accessible service development.                                                                                                             - EoC Action Plan 2006/07                                                                                                                                                                                                                         - HCS C8a                     - 1/4ly reports from
                                                                                                                                                                             - Complaints, SUI & Claims Sub Group identifies areas of poor practice & trends &                                                                                                                                                                                               Complaints, SUI & Claims
                                                                                                                                                                             ensures change occurs
                                                                                                                                                                             - Systems in place to deal with poor performance of individuals
                                                                                                                                                                                                                                                                                                                                                                                                                                                             Sub Group to the Care
                                                                                                                                                                             - EoC is a regular agenda item in all Clinical Governance forums & is incorporated into                                                                                                                                                                                         Services Board.
                                                                                                                                                                             all formal Clinical Governance reporting systems                                                                                                                                                                                                                                - Essence of Care Audit
                                                                                                                                                                             - Standards/audits written for EoC for record keeping & storage
                                                                                                                                                                             - Standards/audit circle for EoC for privacy & dignity for both service user & staff
                                                                                                                                                                                                                                                                                                                                                                                                                                                             - Minutes of Provider
                                                                                                                                                                             - Audit programme for EoC for 2006/07                                                                                                                                                                                                                                           Governance Committee to the
                                                                                                          C8a                                                                - Patient representative sits on EoC Group                                                                                                                                                                                                                                      Care Services Board
                                                                                                          C13a                                                               - EoC feeds into PPI Forum
                                                                                                                                                                             - Standards been developed for PPI involvement
                                                                                                                                                                                                                                                                                                                                                                                                                                                             - HCS C17, C14c
                                                                                                          C13b                                                               - EoC website for communication & sharing best practice
                                                                                                          C20a                                                               - Record keeping training provided
                                                                                                          C20b                                                               - EoC leaflets & posters
                                                                                                                                                                             '- To continue to role out benchmarking topics in order if priority (2006/07 promoting
                                                                                                          C21                                                                health/communication & nutrition)
                                                                                                          D2b                                                                - Explored & establish alternative ways of networking & sharing best practice within the
                                                                                                          D12a                                                               PCT
                                                                                                                                                                             - Explored & develop opportunities to benchmark Essence of Care topics outside the
                                                                                                          D12b                                                               PCT
                                                                                                                                                                             - EoC incorporated into business plans & job descriptions
                                                                                                                                                                             - EoC part of the new provider clinical governance frmaework & make links to better
                                                                                                                                                                             metrics
                                                                                                                                                                             - All audits
                                                                                                                                                                             - Supported the PCT in ensuring that service users are engaged in the business unit
                                                                                                                                                                             development program
                                                                                                                                                                             - Ensured service users are involved in the annual patient environment inspections
                                                                                                                                                                             - Worked with service users and carers to seek new opportunities for effective service
                                                                                                                                                                             user engagement.
                                                                                                                                                                             - Supported the development of a patient centred approach through integrated care
                                                                                                                                                                             planning and monitoring
                                                                                                                                                                             - Continued to develop the roll out of the essence of care program and evaluate
MD3                Develop responsive and meaningful          workforce KW                Y                       MD3.2 Difficulty in recruitment and retention of           - Review, agree and monitor mandatory training for doctors                                      8          #REF!       #REF!            - Develop intranet pages for doctors appraisal and CPD          8           #REF!        #REF!            - HCS C5c, C8b, C11a,         - C11b                           No                No
                   planning within the Medical Directorate               M                                         (CS) Medical Staff                                        within the PCT                                                                                                                          - Develop the use of the online Multi Source feedback                                                     C11c
                                                                                                                                                                             - Review the Study Leave Policy for doctors                                                                                             mechanism for doctors
                                                                                                          C5c                                                                - Ensure that doctors annual appraisals are undertaken,                                                                                 - Develop Mentorship Scheme for GPs
                                                                                                          C5d                                                                including a review of training and completion of PDP forms
                                                                                                          C8b                                                                - Refine Job Planning of Consultants to facilitate a more
                                                                                                          C10b                                                               effective use of resources
                                                                                                          C11a                                                               - Develop continuing professional development for doctors
                                                                                                          C11b                                                               within the PCT
                                                                                                          C11c                                                               - Medical Directors in post
                                                                                                                                                                             - Exit Strategy in place


MD3                Develop responsive and meaningful          workforce KW                Y                       MD3.1 Under performance of doctors                         - Appraisal process and job planning                                                            8          #REF!       #REF!            - Develop intranet pages for doctors appraisal and CPD          8           #REF!        #REF!            - HCS C5c, C8b, C11a,         - Annual appraisals and job      No                No
                   planning within the Medical Directorate               M                                         (CS)                                                      - Review, agree and monitor mandatory training for doctors                                                                              - Develop the use of the online Multi Source feedback                                                     C11c                          plan for all medical staff and
                                                                                                                                                                             within the PCT                                                                                                                          mechanism for doctors                                                                                                                   GPs
                                                                                                                                                                             - Review the Study Leave Policy for doctors                                                                                             - To develop an external appraisal                                                                                                      - HCS C10b, C11b
                                                                                                          C5c                                                                - Ensured that doctors annual appraisals are undertaken,
                                                                                                          C5d                                                                including a review of training and completion of PDP forms
                                                                                                          C8b                                                                - Refine Job Planning of Consultants to facilitate a more
                                                                                                          C10b                                                               effective use of resources
                                                                                                          C11a                                                               - Develop continuing professional development for doctors
                                                                                                          C11b                                                               within the PCT
                                                                                                          C11c                                                               - Primary care tutor in post
                                                                                                                                                                             - Developed Mentorship Scheme for GPs



OD6                Maintain and further develop partnership working to   KT               Y                       OD6.1 Uncoordinated service provision and                  - PIA                                                                                           8          #REF!       #REF!            - Secure income for Hydrotherapy service provided to            8           #REF!        #REF!            - CSCI Inspections            - JAG Minutes                    No                No
                   improve the quality and services provided in the                                                (CS) developments if non involvement of                   - Pooled budgets                                                                                                                        BHNFT                                                                                                                                   - Care Services Board
                   Operational Business Units                                                                           partnership working within Operational               - Clients board structure                                                                                                               -Complete option appraisal for expansion of inpatient                                                                                   - PCT Board
                                                                                                                        Business Units                                       - Integrated mnagament arrangements                                                                                                     substance misuse services                                                                                                               - Client Board
                                                                                                                                                                             - Joint Commissioning                                                                                                                   -Initiate work programme and action plan for Improving                                                                                  - HCS C6
                                                                                                                                                                                                                                                                                                                     Access to Psychological Therapies
                                                                                                                                                                                                                                                                                                                     -Negotiate additional business through MSK service
                                                                                                                                                                                                                                                                                                                     development proposals with PCT Commissioner
                                                                                                                                                                                                                                                                                                                     -Agree and implement revised MSK services specification
                                                                                                                                                                                                                                                                                                                     from October 2007
                                                                                                                                                                                                                                                                                                                     -Negotiate additional business through Podiatric Surgery
                                                                                                          C1                                                                                                                                                                                                         business development proposal.
                                                                                                          C3                                                                                                                                                                                                         -Negotiate additional business through Frail Elderly
                                                                                                          C4                                                                                                                                                                                                         business development proposal
                                                                                                          C6                                                                                                                                                                                                         - Negotiate additional business through Community
                                                                                                          C13                                                                                                                                                                                                        Continence & Urology Service proposal for women under
                                                                                                                                                                                                                                                                                                                     65.
                                                                                                                                                                                                                                                                                                                     -Sexual Health & Family Planning Service Review &
                                                                                                                                                                                                                                                                                                                     Development Plan
                                                                                                                                                                                                                                                                                                                     - Diversity Strategy Action Plan
                                                                                                                                                                                                                                                                                                                     - Race Equality action plan
                                                                                                                                                                                                                                                                                                                     - Develop a clinical management system
                                                                                                                                                                                                                                                                                                                     - Development of business links
                                                                                                                                                                                                                                                                                                                     - Progress all projects contained within the Business
                                                                                                                                                                                                                                                                                                                     Development/Business register


HR5                To develop ESR in order to meet the PCT's GM                           Y                       HR5.1 - Inefficient and ineffective HR                     - ESR system                                                                                    8          #REF!       #REF!            - Identify the capacity of ESR for supporting workforce         8           #REF!        #REF!            - Internal audit report ref                                    No                No
                   requirements and to produce improved information                                                (CS) information systems which does not                   - HR Indicator Reports                                                                                                                  decisions                                                                                                 06/07 15 payroll esr
                   to support decision making.                                                                          support the PCT's business.                          - Complete project on work structures.                                                                                                  - Pilot for pensions
                                                                                                          C7e                                                                - Progressed ESR 'self service' for managers.
                                                                                                          C10a                                                               - Ensured all ESR users receive relevant training.
                                                                                                          C11a                                                               - Considered options for maintaining ESR training within the
                                                                                                           D6                                                                PCT.
                                                                                                                                                                             - Considered feasibility and options for self rostering for
                                                                                                                                                                             implementation in 07/08


HR1                To produce a HR strategy which will support the GM                     Y                       HR1.3 - Failure to comply with                             - Diversity Strategy & Race Equality Scheme in place                                            8          #REF!       #REF!            - To agree & implement PCT Dignity at Work Policy               8           #REF!        #REF!            - Strategic Health            - Diversity Group monitor        No                No
                   reconfiguration of the PCT to reflect the split                                                 (CS) legislation/guidance in relation to                  - Equal Opportunities legislation implemented                                                                                           - To review provision & delivery of Diversity Training                                                    Authority performance         trends & plans re Diversity
                   between Care Services and Commissioning                                                C7e           discrimination, equality & human rights -            - PCT Diversity Group Monitoring Function                                                                                               - To produce a Disability Equality Scheme                                                                 framework                     Strategy
                   Functions.                                                                             C8b           for employment                                       - Annual Equality Report                                                                                                                - Produce an outline plan for the Care Services Board                                                     - Commission for Race
                                                                                                                                                                                                                                                                                                                     - Consult on the plan throughout the PCT.                                                                 Equality Adhoc audits
                                                                                                                                                                                                                                                                                                                     - Produce final HR strategy                                                                               - HCS C7e, C8b




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                                                                                                                                                                                                                          CARE SERVICES ASSURANCE FRAMEWORK




Objective Number




                                                                                        Care Services
 Business Unit




                                                                        Lead Director




                                                                                                                   Risk Number




                                                                                                                                                                                                                                                                           Traffic Light




                                                                                                                                                                                                                                                                                                                                                                                            Traffic Light
                                                                                                                                                                                                                                              Risk Rating




                                                                                                                                                                                                                                                                                                                                                             Risk Rating
                                                                                                        Mapped                                                                                                                                                                                                                                                             Residual Risk                     Assurance - External          Internal Management                                 Gaps in
                              DIRECTORATE OBJECTIVE                                                                                               RISK                                          Existing Controls                                           Risk Rating                                          Planned Controls                                                                                                                                      Gaps In Control
                                                                                                        to HCS                                                                                                                                                                                                                                                                Rating                          (inc Internal Audit)              Assurance                                     Assurance



HR6                To put in place processes to develop responsive and GM                Y                       HR6.1 - Organisation does not have right skills - HR Reports to Managers                                                          8          #REF!       #REF!            - Identify capacity of ESR to support workforce planning.              8           #REF!        #REF!            - Reference Costs           - Reference costs              No                No
                   meaningful workforce planning.                                                                 (CS) in right place for services.              - FIMS Returns                                                                                                            - To work with the Quality Performance Directorate to                                                            - HCS C11a, C11c            - HCS C11b
                                                                                                                       Inefficient decision making.              - Revised Board Report to incorporate Agency spend &                                                                      ensure that all future PCT business plans included
                                                                                                                                                                 recruitment advertising                                                                                                   identification of associated staff numbers/skills
                                                                                                                                                                 - Review of skill mix in service (e.g. Choose & Book in                                                                   - To work with the PCT modernisation team to ensure that
                                                                                                                                                                 Physiotherapy)                                                                                                            all service developments include identification of
                                                                                                                                                                 - Agreed funding for a Workforce Planning manager post with                                                               associated staff numbers/skills
                                                                                                                                                                 the commissioner. Recruited to post                                                                                       - To establish systems & processes for evaluations overall
                                                                                                                                                                                                                                                                                           & enagaging PCT workforce demands
                                                                                                         C11a                                                                                                                                                                              - To establish information systems to facilitate identification
                                                                                                         C11b                                                                                                                                                                              of potential issues affecting workforce eg labour market
                                                                                                         C11c                                                                                                                                                                              intellegence; retirement/recruitment/turnover hotpots;
                                                                                                         D5a                                                                                                                                                                               qualification/skills registers
                                                                                                         D5b                                                                                                                                                                               - To establish reporting systems & management processes
                                                                                                          D7                                                                                                                                                                               to control costs associated with the use of agency staff
                                                                                                                                                                                                                                                                                           - To scope resource requirements to enable the PCT to
                                                                                                                                                                                                                                                                                           make this process sustainable




  Fi3              To enhance the financial information provided to SH                   Y                        Fi3.1          - PCT not able to respond to the      - Disaster Recovery Plan                                                    4          #REF!       #REF!            - To ensure that budget holders have received sufficient               4           #REF!        #REF!            - Internal Audits of main                                  No                No
                   budget holders to aid efficient and effective decision                                         (CS)           modernisation agenda. PCT not able to - Debtors & Income system                                                                                           training to effectively use the new financial system                                                             financial systems &
                   making                                                                                                        access timely financial information   - Capital charges system                                                                                            - To Develop web based budgeting and purchase order                                                              action plans
                                                                                                                                                                       - New ledger system 'Great Plains' installed 01.04.06                                                               processing elements within the system                                                                            - HCS C7d - ALE
                                                                                                                                                                       - Completed the implementation of the new financial systems
                                                                                                         C7d
                                                                                                                                                                       - Explored the opportunities for investing in a service costing
                                                                                                         C7f
                                                                                                                                                                       system in relation to the provider arm.




  Fi4              To respond to the business requirements of PCT SH                     Y                        Fi4.1          PCT is not able to respond to current    - Competent trained workforce with qualified accountants and             4          #REF!       #REF!            - To establish a Waste Management and Contracts                        4           #REF!        #REF!            - Internal audit reports   - Board monthly finance         No                No
                   Commissioners and Providers by influencing and                                                 (CS)           business requirements                    support structures                                                                                               Manager role to ensure the PCT complies with legislation                                                         - Accounting and general reports
                   supporting areas of development                                                                                                                        - Financial information and budget management accountability                                                                                                                                                                      ledger and accounting
                                                                                                                                                                          structure                                                                                                                                                                                                                         funcitons
                                                                                                                                                                          - Director of Finance                                                                                                                                                                                                             - District Audit opninions
                                                                                                         C7d                                                              - Reviewed the current arrangements for the finance function                                                                                                                                                                      - SHA monthly reporting
                                                                                                         C7f                                                              to support both elements of the PCT                                                                                                                                                                                               - HCS C7d - ALE
                                                                                                                                                                          - Ensured staff have the tools to work effectively in their
                                                                                                                                                                          respective roles



PQ 4               Ensure that the PCT has effective Governance         SB               Y                       PQ 4.3 - Failure to comply with legislation - SFI, SO & SOD                                                                       4          #REF!       #REF!            - Maintain a programme of review of current policies &                 4           #REF!        #REF!            - Internal Audit Reports    - Policies approved by Board   No                No
                   arrangements in place to mitigate risk to the                                                  (CS) through     inadequate  policies    & - Clinical Policies & Procedures, Health & Safety Risk                                                                        procedures                                                                                                       Financial systems           - Procedures approved by
                   organisation in accordance with national guidance                                                    procedures                           Assessment manuals                                                                                                            - Develop a 'Policy on Policies'                                                                                 - Head of Internal Audit    relevant Lead Director
                                                                                                                                                             - Employment Policies                                                                                                         - To Develop and implement a governance system (for                                                              Opinion Statement           - Annual Report to the Board
                                                                                                                                                             - Operational Poicies                                                                                                         policies and procedures) within the PCT                                                                          - Internal Audit Report     - SIC
                                                                                                                                                                                                                                                                                           - To Provide required statutory documents and appropriate                                                        Risk Management 06/07
                                                                                                         C1a                                                                                                                                                                               governance reports, for example the assurance framework,                                                         Ref 11
                                                                                                         C7a                                                                                                                                                                               the statement on internal control and risk management                                                            - HCS C7a
                                                                                                         C8a                                                                                                                                                                               annual reports
                                                                                                         D1                                                                                                                                                                                - To co-ordinate external assessment processes
                                                                                                         D3                                                                                                                                                                                (Healthcare Standards, NHSLA, ALE) and collation of
                                                                                                         D4a                                                                                                                                                                               required evidence portfolios
                                                                                                         D4b                                                                                                                                                                               - To develop and undertake a Governance Audit within the
                                                                                                                                                                                                                                                                                           PCT
                                                                                                                                                                                                                                                                                           - Devise and deliver Risk Management Training for Board
                                                                                                                                                                                                                                                                                           Members and Senior Managers



PQ 3               Facilitate improvements in the quality of care and   SB               Y                       PQ 3.2 - Patients are harmed or treated                  - Intervential Procedures Policy                                         4          #REF!       #REF!            - Encourage Staff to improve incident investigation and to             4           #REF!        #REF!            - HCS C5a                   - Monitoring of PCT practice No                  No
                   services                                                                                       (CS) unethically through PCT failure to                 - Interventional Procedures documented within clinical policies                                                  identify 'lessons learnt' from incidents for dissemination as                                                                                against NICE IPG Programme
                                                                                                                        govern the use of new interventional              & procedures system with required competencies attached                                                          appropriate across the PCT                                                                                                                   - HCS C3
                                                                                                                        procedures                                        - Interventional procedures accurred across the organisation                                                     - Develop and provide risk management training focusing
                                                                                                                                                                          reviewed & included in Clinical Policies & Procedure system                                                      on general incident reporting, responsible persons and risk
                                                                                                                                                                          - Maintained a system for the receipt of external alert                                                          management for Managers
                                                                                                                                                                          notifications and processes for distribution and the monitoring
                                                                                                         C3                                                               of returns
                                                                                                         C5a                                                              - To oversee the development of best practice via the Essence
                                                                                                         D4b                                                              of Care Toolkit and to provide training as appropriate, including
                                                                                                                                                                          the setting up of sub groups to focus on particular
                                                                                                                                                                          benchmarks.




PQ 3               Facilitate improvements in the quality of care and   SB               Y                       PQ 3.3 - PCT delivers ineffective services                - Reviewed , developed and monitored performance and                    4          #REF!       #REF!             - Encourage staff to improve incident investigation and to            4           #REF!        #REF!            - HCS C5a                   - Monitoring of PCT practice No                  No
                   services                                                                                       (CS) through failure to performance manage              reported on achievement of the Quality Care Services                                                             identify 'lessons learnt' from incidents for dissemincation as                                                                               against NICE IPG Programme
                                                                                                                        and audit its clinical services (linked to        Framework                                                                                                        appropriate across the PCT                                                                                                                   - HCS C3
                                                                                                                        risk PQ 9.1(CS)                                   - Established robust systems to collate, record and report on                                                    - Maintain systems for the receipt of external alert
                                                                                                                                                                          information related to the quality agenda and produce                                                            notifications and processes for distribution and the
                                                                                                                                                                          meaningful reports for business units and other partnership                                                      monitoring of returns
                                                                                                                                                                          agencies                                                                                                         - develop and provide risk management training focusing
                                                                                                                                                                          - In line with National and Local Guidance negotiated and                                                        on general incident reporting, responsible persons and risk
                                                                                                                                                                          agreed and monitored quality standards between the PCT and                                                       management for managers
                                                                                                                                                                          its business units, including areas that involve partnership                                                     - Develop a Quality Strategy
                                                                                                         C3                                                               working                                                                                                          - Further develop systems to monitor and review complaints
                                                                                                         C5a                                                              - Coordinated and reviewed Record keeping Standards within                                                       and to ensure that lessons are learned and changes are
                                                                                                         D4b                                                              the trust                                                                                                        implemented to improve the experience of Patients
                                                                                                                                                                          - To oversee the development of best practice via the Essence
                                                                                                                                                                          of Care Toolkit and to provide training as appropriate, including
                                                                                                                                                                          the setting up of sub groups to focus on particular
                                                                                                                                                                          benchmarks.
                                                                                                                                                                          - Ensured that Quality Leads are identified and trained for each
                                                                                                                                                                          new Care Services Business Unit
                                                                                                                                                                          - System in place to oversee the Trust Wide audits
                                                                                                                                                                          - CS8, CS9 Storage System




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Objective Number




                                                                                         Care Services
 Business Unit




                                                                         Lead Director




                                                                                                                    Risk Number




                                                                                                                                                                                                                                                                                 Traffic Light




                                                                                                                                                                                                                                                                                                                                                                                                Traffic Light
                                                                                                                                                                                                                                                 Risk Rating




                                                                                                                                                                                                                                                                                                                                                                 Risk Rating
                                                                                                         Mapped                                                                                                                                                                                                                                                                Residual Risk                     Assurance - External          Internal Management                                Gaps in
                              DIRECTORATE OBJECTIVE                                                                                                 RISK                                            Existing Controls                                          Risk Rating                                            Planned Controls                                                                                                                                    Gaps In Control
                                                                                                         to HCS                                                                                                                                                                                                                                                                   Rating                          (inc Internal Audit)              Assurance                                    Assurance



  IS3              Planning and Implementation of improvement to         SH               Y                       IS3.2           Organisation unable to manage records       - Roles and responsibilities of Operational Staff                  12              #REF!         #REF!              - Procedure for creation, storage and disposal of records to        6           #REF!        #REF!            HCS - C9                                                  No                No
                   support PCT health records management                                                           (CS)           effectively as information services not     - medical Records policy                                                                                           all staff by end 07/08                                                                                         - Twice yearly audits
                                                                                                                                  empowered to provide adequate               - Produced a Business case for PCT centralised records                                                             - Development of Policy by year end 08/09                                                                      - 7 agreed standards.
                                                                                                                                  centralised support and PCT continued       service                                                                                                            - Procurement of PCT records management system
                                                                                                                                  reliance on paper based systems             - Records digitisations options, separate to but linked to                                                         - Implementation of PCT records management system
                                                                                                          C9                                                                  Business Case for PCT                                                                                              08/09
                                                                                                                                                                              - Develop corporate approach to operational service control of
                                                                                                                                                                              records



  IS3              Planning and Implementation of improvement to         SH               Y                       IS3.1           Organisation unable to satisfactorily       - Commercial offsite facility available (Leeds)                    12              #REF!         #REF!             - System 1 is PCT's Electronic Clinical Records System.              6           #REF!        #REF!            - Record keeping audits                                   No                No
                   support PCT health records management                                                           (CS)           meet fundamental records keeping            - Records Management Policies                                                                                      As each service moves over to System 1, a discussion will                                                      - HCS C9
                                                                                                                                  standards, with resultant gaps in           - Information Governance Officer appointed                                                                         be held with that individual service unit about scope of
                                                                                                                                  assurance                                   - Creation of additional storage on Kendray Hospital site                                                          electronic health records being stored on the system.
                                                                                                                                                                              - Information Governance Policy
                                                                                                                                                                              - Health Records Policy
                                                                                                                                                                              - PCT Confidentiality Policy & Code of Conduct
                                                                                                                                                                              - Procedure on storage & destruction of records
                                                                                                                                                                              - IR1 systems for reporting non-availability of notes
                                                                                                                                                                               Targeted information governance toolkit compliance level 2
                                                                                                                                                                              for all items by 2007 submission
                                                                                                                                                                              - Integrated Information Governance within 'Integrated
                                                                                                          C9                                                                  Governance' approach in PCT
                                                                                                                                                                              - Roles and responsibilities of Operational Staff
                                                                                                                                                                              - Medical Records policy
                                                                                                                                                                              - Produced a Business case for PCT centralised records
                                                                                                                                                                              service
                                                                                                                                                                              - Records digitisations options, separate but linked to Business
                                                                                                                                                                              Case for PCT records service
                                                                                                                                                                              - Develop corporate approach to operational service control of
                                                                                                                                                                              records




PQ 8               Develop the external communications and marketing     SB               Y                       PQ 8.1 -   Lack     of   Proactive  external                - PCT Annual report                                                12              #REF!         #REF!             - Write and implement an external communications strategy            6           #REF!        #REF!            - Regular reports from - Monthly reports to               No                No
                   function for the PCT to enhance the corporate image                                             (CS) communications - leading to increased                 - Patient Prospectus                                                                                               - Develop, launch and maintain the new external website for                                                    SHA on media coverage Communications Group
                   and increase awareness of services it provides                                                        negative media coverage, resulting in                - Support national NHS media/PR campaigns locally                                                                  the PCT                                                                                                        - HCS C16
                                                                                                                         poor corporate image                                 - Communications strategy approved by Board
                                                                                                                                                                              - PPI leaflets
                                                                                                                                                                              - Policies & procedures
                                                                                                                                                                                - PPI strategy
                                                                                                                                                                                - Consultation protocol
                                                                                                                                                                                - Guidance for the production & procedure for the approval of
                                                                                                          C16                                                                 PPI
                                                                                                                                                                              - External Communication/Marketing Manager in Post
                                                                                                                                                                              - Created and managed a proactive approach to press
                                                                                                                                                                              releases and dealing with new stories
                                                                                                                                                                              - Updated processes to ensure a consistent approach to
                                                                                                                                                                              Marketing across the PCT




   E1              Oversee the commissioning and construction of the     NM               Y                        E1.2           Failure to operationalize the Mental         - Ensured project board and project team oversee                  12              #REF!         #REF!              - Complete construction phase and handover to Barnsley              9           #REF!        #REF!            - HCS C21, C20a,           LDP                            No                No
                   new Mental Health Unit at Kendray Hospital in line                                     C20a    9(CS)           Health Unit Build by April 2008             continuation and variation of design                                                                               PCT                                                                                                                                       - HCS C20b
                   with the project brief                                                                 C20b                                                                - Ensured Equipment group is set up and order suitable                                                             - Commission building equipment and service with users                                                                                    - Confirmed date of opening
                                                                                                          C21                                                                 equipment to be delivered to site and commissioned                                                                 and supplier
                                                                                                          D12a
                                                                                                          D12b

  Fi2              To contribute to the effective control of and SH                       Y                       Fi2.3           Financial implications for the Care         - Agenda for change                                                12              #REF!         #REF!             - To produce robust forecasts on income and expenditure         12               #REF!        #REF!            - Performance monitoring                                  Yes               Yes - Risk at the
                   achievement of financial statutory duties                                                      (CS)            Services and Commissioning Services         - Signed up to the NHS Litigation Authority                                                                        on a monthly basis                                                                                             by SHA                                                                      moment is an
                                                                                                                                  as a result of equal pay for equal value.   - Secured the Services of a solicitor from the NHS Litigation                                                      - To support the development of cost improvement                                                               - Solicitors monitoring                                                     unknown quantity
                                                                                                                                  (as a result of agenda for change)          Authority                                                                                                          programmes and saving schemes in consultation with                                                             deadlines (i.e provision
                                                                                                                                                                                                                                                                                                 budget holders                                                                                                 of information to meet
                                                                                                                                                                                                                                                                                                 - To support the Commissioning Directorate in the                                                              legislative deadlines.
                                                                                                                                                                                                                                                                                                 production of the Local Delivery Plan and ongoing                                                              - HCS C7d -ALE
                                                                                                                                                                                                                                                                                                 monitoring, including submissions to the Strategic Health
                                                                                                                                                                                                                                                                                                 Authority.
                                                                                                                                                                                                                                                                                                 - To performance manage the organisation in respect of its
                                                                                                                                                                                                                                                                                                 statutory financial requirements.




  SI1              Deliver the service change/development outcomes SR                     Y                       SI1.2           Failure to    innovate    and    Improve - Project register template agreed                                         9 Medium Risk          Green               - Populate project register with key service improvement             6           #REF!        #REF!            No                         - Contract GP Monitoring                         Yes
                   across agreed priority areas set out in the Business                                           (CS)            Services                                 -Negotiated revised MSK service contract with PCT                                                                     innovation projects                                                                                                                       - Prune two project reviews
                   Development Project Register                                                                                                                            Commissioner based on agreement of local tariff.                                                                      -Complete option appraisal for expansion of inpatient                                                                                     with in built assurance
                                                                                                                                                                           - Business development/change register                                                                                substance misuse services
                                                                                                                                                                           - Secured income for Hydrotherapy service provided to BHNFT                                                           - Progress all projects contained within Business
                                                                                                                                                                           - Agreed and implement revised MSK services specification                                                             development/register
                                                                                                                                                                           from October 2007
                                                                                                                                                                           -Initiated work programme and action plan for Improving
                                                                                                          C18                                                              Access to Psychological Therapies
                                                                                                          D11a                                                             -Negotiated additional business through MSK service
                                                                                                          D11b                                                             development proposals with PCT Commissioner
                                                                                                          D11c                                                             -Negotiated additional business through Podiatric Surgery
                                                                                                          D11d                                                             business development proposal.
                                                                                                                                                                           -Negotiated additional business through Frail Elderly business
                                                                                                                                                                           development proposal
                                                                                                                                                                           - Negotiated additional business through Community
                                                                                                                                                                           Continence & Urology Service proposal for women under 65.
                                                                                                                                                                           -Sexual Health & Family Planning Service Review &
                                                                                                                                                                           Development Plan



  SI4              To maximise PCT provider income.                      SR               Y                       SI4.1           The PCT misses market opportunities - Market PCT Provider Services for organisations outside of                     9 Medium Risk          Green                                                                                    3           #REF!        #REF!                                       - Actively review tender issued Yes              Yes
                                                                                                                  (CS)            for Development and Growth          Barnsley                                                                                                                                                                                                                                                             by neighbouring PCT's for bus
                                                                                                                                                                      - Innitate discussions with Neighbouring PCTs re services                                                                                                                                                                                                            opps.
                                                                                                          C7d                                                                                                                                                                                                                                                                                                                              - Directory of services




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Objective Number




                                                                                             Care Services
 Business Unit




                                                                             Lead Director




                                                                                                                        Risk Number




                                                                                                                                                                                                                                                                                            Traffic Light




                                                                                                                                                                                                                                                                                                                                                                                                            Traffic Light
                                                                                                                                                                                                                                                               Risk Rating




                                                                                                                                                                                                                                                                                                                                                                          Risk Rating
                                                                                                             Mapped                                                                                                                                                                                                                                                                     Residual Risk                        Assurance - External            Internal Management                                 Gaps in
                               DIRECTORATE OBJECTIVE                                                                                                    RISK                                                Existing Controls                                                Risk Rating                                        Planned Controls                                                                                                                                         Gaps In Control
                                                                                                             to HCS                                                                                                                                                                                                                                                                        Rating                             (inc Internal Audit)                Assurance                                     Assurance



  IS5              Agree service levels with Business Units and raise        SH               Y                        IS5.1          Provider Services are unable to operate      - data quality checking in preparation of activity reports for the               9          #REF!       #REF!            - data warehouse project                                           6           #REF!          #REF!             - data sets sent to DOH                                      No                No
                   the profile of health intelligence within the PCT                                                    (CS)          as a business because of a potential         board.                                                                                                                   - data quality policy to be developed                                                                           have to meet technical
                                                                                                                                      lack of income due to inability to           - regular feedback to operational service joint management                                                               - ALE recommendation review of data quality of all board                                                        requirements for data
                                                                                                                                      provider performance management              team meeting                                                                                                             reports to be undertaken by internal audit.                                                                     quality to be accepted for
                                                                                                                                      information internally and externally will   - clinical coding function and support to PCT                                                                            - Formalise service level for responding to adhoc requests.                                                     loading. Loading
                                                                                                                                      jeapodise the business                       - Reviewed and redistributed workload within team                                                                        - Agreements with identified Business Units                                                                     acceptance reports sent
                                                                                                                                                                                   - Reviewed structure of team                                                                                                                                                                                                             to PCT.
                                                                                                              D6                                                                                                                                                                                                                                                                                                            - supplying and
                                                                                                                                                                                                                                                                                                                                                                                                                            submitting data for the
                                                                                                                                                                                                                                                                                                                                                                                                                            annual health check.
                                                                                                                                                                                                                                                                                                                                                                                                                            * Internal Audit of
                                                                                                                                                                                                                                                                                                                                                                                                                            information reported to
                                                                                                                                                                                                                                                                                                                                                                                                                            PCT Board

  IS7              Implementation of Data warehouse within the SH                             Y                        IS7.1          - Care Services are unable to operate as     - data quality checking in preparation of activity reports for the               9          #REF!       #REF!                                                                               6           #REF!          #REF!             - data sets sent to DOH                                      No                No
                   provider and commissioner functions of the PCT to                                                    (CS)          a business because of a potential lack       board.                                                                                                                                                                                                                                   have to meet technical
                   improve decision support and information reporting.                                                                of income due to inability to Care           - regular feedback to operational Service joint management                                                                                                                                                                               requirements for data
                                                                                                                                      Services performance management              team meeting                                                                                                                                                                                                                             quality to be accepted for
                                                                                                                                      information internally and externally will   - clinical coding function and support to PCT                                                                                                                                                                                            loading. Loading
                                                                                                                                      jeopardise the business                      - Reviewed and redistributed workload within team                                                                                                                                                                                        acceptance reports sent
                                                                                                                                                                                   - Awarded contract to preferred supplier                                                                                                                                                                                                 to PCT.
                                                                                                              D6                                                                   - Establishment of project team                                                                                                                                                                                                          - supplying and
                                                                                                                                                                                   - Implemented activities and plans approved by the project                                                                                                                                                                               submitting data for the
                                                                                                                                                                                   team                                                                                                                                                                                                                                     annual health check.
                                                                                                                                                                                   - Implementation of phase 1 of Provider data warehouse
                                                                                                                                                                                   development



  IS6              Improve data capture and quality within the Care          SH               Y                        IS6.1          Provider Services are unable to operate      - data quality checking in preparation of activity reports for the               9          #REF!       #REF!            - Develop PCT Data Quality Policy                                  6           #REF!          #REF!             - data sets sent to DOH                                      No                No
                   Services part of the PCT                                                                             (CS)          as a business because of a potential         board.                                                                                                                   - Engage with Service managers and agree recording                                                              have to meet technical
                                                                                                                                      lack of income due to inability to           - regular feedback to operational service joint management                                                               protocols for identified Business Units                                                                         requirements for data
                                                                                                                                      Provider performance management              team meeting                                                                                                                                                                                                                             quality to be accepted for
                                                                                                                                      information internally and externally will   - clinical coding function and support to PCT                                                                                                                                                                                            loading. Loading
                                                                                                              D6                      jeopardise the business                      - Reviewed and redistributed workload within team                                                                                                                                                                                        acceptance reports sent
                                                                                                                                                                                                                                                                                                                                                                                                                            to PCT.
                                                                                                                                                                                                                                                                                                                                                                                                                            - supplying and
                                                                                                                                                                                                                                                                                                                                                                                                                            submitting data for the
                                                                                                                                                                                                                                                                                                                                                                                                                            annual health check.


  Fi2              To contribute to the effective control of and SH                           Y                        Fi2.4          Cash Flow Implications affected by SCG - Strong working relationship between PCT and SCG South                                9          #REF!       #REF!            - Recharge infor to be established before 1 April 2008             9 Low Risk               Dark Green - Annual accounts audit                                               No                No
                   achievement of financial statutory duties                                                           (CS)           South transactions                     Finance Staff                                                                                                                                                                                                                         letter from audit
                                                                                                                                                                             - Regular Finance Review meeting between PCT and SCG                                                                                                                                                                                  commission
                                                                                                                                                                             South
                                                                                                                                                                             - Budget
                                                                                                                                                                             - Statements monthly
                                                                                                                                                                             - Cashflow projections agreed throughout the year




PQ 10              Clinical Audit.                                           SB               Y                       PQ 10.1 - PCT delivers ineffective services                  Clinical Audit:                                                                  9          #REF!       #REF!            - More comprehensive audit plan including audit of NICE            9           #REF!          #REF!             - HCS C7a                    - Claude database of audit      No                No
                                                                                                                       (CS) through failure to Performance Manage                  - Service Level Agreement for Clinical Audit                                                                             Guidance                                                                                                        - Internal audit report      undertaken
                   To improve patient care and outcomes through                                                               and audit its clinical services                      - Discussion at care groups                                                                                              - Identify & prioritise the clinical audit programme in                                                         07/08 ref 7 follow up        - Reports on clinical audits
                   systematic review of care against explicit criteria and                                                                                                         - Topic identification tool                                                                                              conjunction with service areas & independent contactors,                                                        medicines management         schedule to Provider
                   the implementation of change.                                                                                                                                   Evaluation/Research                                                                                                      taking into account the Service Level Agreements for                                                                                         Governance Committee
                                                                                                                                                                                   - Research Governance Sub Group - revise research proposals
                                                                                                                                                                                                                                                                                                            Clinical Audit                                                                                                                               - Clinical audit schedule for
                                                                                                                                                                                   - Research Alliance
                                                                                                                                                                                                                                                                                                            - Bring Clinical Audit Function in house                                                                                                     Care Services
                                                                                                                                                                                   - LREC
                                                                                                                                                                                   - Maintained a system for the receipt of external alert notifications and                                                - to develop a Clinical Audit Stategy
                                                                                                                                                                                   processes for distribution and the monitoring of returns                                                                 - Develop a Clinical Audit Policy.
                                                                                                                                                                                   - Reviewed Clinical Audit support within the PCT, in relation to the
                                                                                                                                                                                   Care Services.
                                                                                                                                                                                   - Reviewed and develop Clinical Audit Training and guidance for Care
                                                                                                              C3                                                                   Services
                                                                                                              C5d                                                                  - Ensured a robust Clinical Audit Schedule with agreed timescales
                                                                                                              C17                                                                  - Ensured there are systems in place for monitoring the delivery of the
                                                                                                                                                                                   audit schedule and ensuring that action plans are implemented
                                                                                                                                                                                   - Overseen the development of Trust-wide Audits
                                                                                                                                                                                   - Implemented an effective storage system of relevant electronic and
                                                                                                                                                                                   paper documents to fulfil the requirements for retention of information
                                                                                                                                                                                   for the Freedom of Information Act and Data Protection Act.
                                                                                                                                                                                   - Developed a reporting database for all audit projects and produce
                                                                                                                                                                                   an Annual Clinical Audit Report




PQ 8               Develop the external communications and marketing         SB               Y                       PQ 8.2 - lack of marketing support to provider - '- External Communications & Marketing Manager in post                                       9          #REF!       #REF!            - Produce marketing template for Provider Services                 9           #REF!          #REF!             - HCS C16                    - Monthly reports to            No                Yes
                   function for the PCT to enhance the corporate image                                                 (CS) functions       leading    to    lack    of - Updated processes to ensure a consistent approach to                                                                              - Provide support to 2 services in 2007/08                                                                                                   Communication Group                               '- (C16 refers to
                   and increase awareness of services it provides                                                            understanding of services provided and marketing across the PCT                                                                                                                - Develop, launch and maintain the new external website for                                                                                                                                    info to Patients
                                                                                                                             'sale' of services through patient choice.                                                                                                                                     the PCT                                                                                                                                                                                        not specifically
                                                                                                              C16                                                                                                                                                                                           - Provide marketing support to Care Services functions                                                                                                                                         Marketing and
                                                                                                                                                                                                                                                                                                            - Write and implement an external communications strategy                                                                                                                                      external
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           communications)




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                                                                                                                                                                                                                                    CARE SERVICES ASSURANCE FRAMEWORK




Objective Number




                                                                                         Care Services
 Business Unit




                                                                         Lead Director




                                                                                                                     Risk Number




                                                                                                                                                                                                                                                                                       Traffic Light




                                                                                                                                                                                                                                                                                                                                                                                                            Traffic Light
                                                                                                                                                                                                                                                          Risk Rating




                                                                                                                                                                                                                                                                                                                                                                             Risk Rating
                                                                                                         Mapped                                                                                                                                                                                                                                                                            Residual Risk                     Assurance - External        Internal Management                                 Gaps in
                               DIRECTORATE OBJECTIVE                                                                                                RISK                                               Existing Controls                                                Risk Rating                                           Planned Controls                                                                                                                                       Gaps In Control
                                                                                                         to HCS                                                                                                                                                                                                                                                                               Rating                          (inc Internal Audit)            Assurance                                     Assurance



PQ 3               Facilitate improvements in the quality of care and    SB               Y                        PQ 3.3 - PCT delivers ineffective services                 Clinical Audit:                                                                  9          #REF!       #REF!            - More comprehensive audit plan including audit of NICE                    9           #REF!        #REF!            - Audit reports to       - Claude database of audit      No                No
                   services                                                                                         (CS) through failure to Performance Manage                - Service Level Agreement for Clinical Audit                                                                             Guidance                                                                                                             Governance Committee     undertaken
                                                                                                                          and audit its clinical services (linked to          - Discussion at care groups                                                                                              - Identify & prioritise the clinical audit programme in conjunction                                                  - Audit Commission       - Monitor research (1-10
                                                                                                                          risk PQ9.1)                                         - Topic identification tool                                                                                              with service areas & independent contactors, taking into account                                                     Reports "Performance     audited to ensure criteria is
                                                                                                                                                                              Evaluation/Research                                                                                                      the Service Level Agreements for Clinical Audit                                                                      Management" - Provider   met)
                                                                                                                                                                              - Research Governance Sub Group - revise research proposals                                                              - Bring Clinical Audit Function in house
                                                                                                                                                                                                                                                                                                                                                                                                                            Services
                                                                                                                                                                              - Research Alliance                                                                                                      - Encourage staff to improve incident investigation and to identify
                                                                                                                                                                                                                                                                                                                                                                                                                            - HCS C7a
                                                                                                                                                                              - LREC                                                                                                                   ‘lessons learnt’ from incidents for dissemination as appropriate
                                                                                                                                                                              - Maintained a system for the receipt of external alert notifications and                                                across the PCT
                                                                                                                                                                              processes for distribution and the monitoring of returns                                                                 - Review, develop, monitor performance and report on
                                                                                                                                                                              - Review Clinical Audit support within the PCT, in relation to the Care                                                  achievement of the Quality Care Services Framework.
                                                                                                                                                                              Services                                                                                                                 - Establish robust systems to collate, record and report on
                                                                                                          C1a                                                                 - Review and Develop Clinical Audit Training and guidance for Care                                                       information related to the quality agenda and produce meaningful
                                                                                                          C5b                                                                 Services                                                                                                                 reports for business units and other partner agencies.
                                                                                                         C14a, b                                                              - Ensured a robust Clinical Audit Schedule with agreed timescales                                                        - Coordinate and review Record Keeping Standards within the
                                                                                                           &c                                                                 - Ensured there are systems in place for monitoring the delivery of the                                                  Trust.
                                                                                                          D4b                                                                 audit schedule and ensuring that action plans are implemented                                                            - To oversee the development of best practice via the Essence of
                                                                                                                                                                              - To oversee the development of Trust - Wide Audits                                                                      Care Toolkit and to provide training as appropriate, including the
                                                                                                                                                                              - Implemented an effective storage system of relevant electronic and                                                     setting up of sub groups to focus on particular benchmarks.
                                                                                                                                                                              paper documents to fulfil the requirements for retention of information                                                  - Ensure that Quality Leads are identified and trained for each
                                                                                                                                                                              for the Freedom of Information Act and Data Protection Act                                                               new Care Services Business Unit
                                                                                                                                                                              - Developed a reporting database for all audit projects and produce                                                      - Develop a Quality Strategy
                                                                                                                                                                              an Annual Clinical Audit Report                                                                                          - Further develop systems to monitor and review complaints
                                                                                                                                                                                                                                                                                                       and to ensure that lessons are learned and changes are
                                                                                                                                                                                                                                                                                                       implemented to improve the experience of patients
                                                                                                                                                                                                                                                                                                       - To develop a Clinical Audit Strategy
                                                                                                                                                                                                                                                                                                       - To develop a Clinical Audit Policy


PQ 3               Facilitate improvements in the quality of care and    SB               Y                        PQ 3.1 - Absence of robust structures for                  - NICE Lead - DoP                                                                9          #REF!       #REF!            - Develop NICE section on PCT intranet                                     9           #REF!        #REF!            - HCS C5a                - NICE Initiation Monitoring & No                 No
                   services                                                                                         (CS) initiating & monitoring implementation of            - NICE Initiation & Best Practice Group                                                                                                                                                                                                                                Best Practice Group progress
                                                                                                                          NICE guidance resulting in failure to               - NICE Database to track progress                                                                                                                                                                                                                                      reports to PCT Clinical
                                                                                                                          adopt evidence based practice & failure             - Agreed systematic system for implementation                                                                                                                                                                                                                          Governance/Best Value
                                                                                                                          to meet statutory requirements                      - Registered Stakeholder                                                                                                                                                                                                                                               Committee
                                                                                                                                                                              - Horizon scanning                                                                                                                                                                                                                                                     - Provider monitored via
                                                                                                          C3                                                                  - NICE assessment & action planning process                                                                                                                                                                                                                            Commissioner Contract
                                                                                                          C5a                                                                 - Provider NICE Policy                                                                                                                                                                                                                                                 Monitoring Process
                                                                                                          D4b                                                                 - Maintained a system for the receipt of external alert                                                                                                                                                                                                                - HCS C3
                                                                                                                                                                              notifications and processes for distribution and the monitoring
                                                                                                                                                                              of returns
                                                                                                                                                                              - Maintained current systems for NICE on behalf of the Care
                                                                                                                                                                              Services.


   E5              Ensure current facilities meet the national guidance NM                Y                         E5.1           - Failure of provider services to operate - Instigate commissioning group for both Grimethorpe and                          9          #REF!       #REF!            - Oversee the construction of Tranche 1B for Grimethorpe                   4           #REF!        #REF!            - PEAT                   - 6 faceted survey as per       No                No
                   and legislation, and all new facilities are designed to                                          (CS)           from fit for purpose accommodation        Cudworth                                                                                                                  and Cudworth Lift premises                                                                                           - ERIC returns           Estate code (appendix to
                   promote effective care and optimise health                                             C20a                                                                                                                                                                                         - Confirm occupation requirements and equipment to                                                                   - HCS C20a, C21          Estates Strategy)
                   outcomes                                                                               C20b                                                                                                                                                                                         Supplies Department for ordering suppliers.
                                                                                                          C21                                                                                                                                                                                          - Progress Tranche 3 to Stage 1 approval
                                                                                                          D12a                                                                                                                                                                                         - Review statutory compliance in regard to planned
                                                                                                          D12b                                                                                                                                                                                         maintenance


   E2              Ensure that the Care Services and Commissioner        NM               Y                         E2.1           - Unplanned (but essential)                - Accommodation Policy                                                           9          #REF!       #REF!            - Consultation with Staff Side/SHA & other key stakeholders                6           #REF!        #REF!            - NHS Estates approval   - Acute MH Project board        No                No
                   arm of the PCT have a robust Estates Strategy to                                                 (CS)           developments leading to additional         - PCT Estates Strategy 2006                                                                                              - Implement strategy in line with in-year developments                                                               of signed off designs
                   meet their requirements                                                                                         financial commitments.                     - Strategic Service Development Plan (SSDP) 5 Year plan                                                                  - Update of SSDP due                                                                                                 - Mental Health Act
                                                                                                                                                                              - Post project evaluations on all projects                                                                               - Site Development Plan for Mount Vernon                                                                             commission visits
                                                                                                                                                                              - Standard Financial Instructions                                                                                        - Business Unit Development Plans (Business Plans)                                                                   - PEAT Inspections
                                                                                                                                                                              - Project Management Guidance document                                                                                   - Review current Estates strategy in line with agreed                                                                - Kings Fund visit -
                                                                                                                                                                              - Design to comply with Health Technical Memorandums                                                                     business plan                                                                                                        Enhancing the healing
                                                                                                                                                                              - (HTMs) & Health Building Notes (HBNs)                                                                                  - Proposed revised strategy to service Re provision board                                                            environment scheme
                                                                                                                                                                              - Clinical involvement in design                                                                                         commissioning OMG                                                                                                    - HCS C20a, C21
                                                                                                          C20a
                                                                                                                                                                              - Health & Safety Executive involvements at design stage                                                                 - Oversea the construction of Tranche AG58 for
                                                                                                          C20b
                                                                                                                                                                              - Designed reviews with Key Stakeholder re SHA & DOH.                                                                    Grimethorpe and Cudworth LIFT premises
                                                                                                          C21
                                                                                                                                                                              - Instigated commissioning group for both Grimethorpe and                                                                - Confirm occupation requirements and equipment to
                                                                                                          D12a
                                                                                                                                                                              Cudworth                                                                                                                 Supplies Department for ordering suppliers
                                                                                                          D12b
                                                                                                                                                                              - Designed all new premises and refurbishments in                                                                        - Progress Tranche 3 to Stage 1 approval
                                                                                                                                                                              collaboration with infection control and health and safety                                                               - Review Statutory compliance in regard to planned
                                                                                                                                                                                                                                                                                                       maintenance
                                                                                                                                                                                                                                                                                                       - Implement accomodation register on all PCT premises
                                                                                                                                                                                                                                                                                                       - Produced business unit occupational reports




   E3              Replacement of Primary Care properties via LIFT NM                     Y                         E3.1           - Failure of provider services to operate - Instigate commissioning group for both Grimethorpe and                          9          #REF!       #REF!            - Oversee the construction of Tranche 1B for Grimethorpe                   4           #REF!        #REF!            - PEAT                   - 6 faceted survey as per       No                No
                   scheme to ensure that services are provided from fit                                   C20a      (CS)           from fit for purpose accommodation        Cudworth                                                                                                                  and Cudworth Lift premises                                                                                           - ERIC returns           Estate code (appendix to
                   for purpose facilities                                                                 C20b                                                                                                                                                                                         - Confirm occupation requirements and equipment to                                                                   - HCS C20a, C21          Estates Strategy)
                                                                                                          C21                                                                                                                                                                                          Supplies Department for ordering suppliers.
                                                                                                          D12a                                                                                                                                                                                         - Progress Tranche 3 to Stage 1 approval
                                                                                                          D12b

   P3              Support the delivery of quality services that meet    MK               Y                         P3.2           - Non compliance with national & local     - Records Management Group                                                       9          #REF!       #REF!                                                                                       9           #REF!        #REF!            - HCS C13b, C13c, C9     - Annual Record Keeping         No                No
                   national and local priorities, ensuring targets are                                              (CS)           record keeping standards creating a        - Clinical Governance Structures                                                                                                                                                                                                                                       Audit
                   achieved.                                                                                                       potential litigation risk and patients     - The PCT's record keeping standards 'raising the standards' have
                                                                                                                                   receiving inappropriate care due to lack   been revised and implemented into the clinical policy manual
                                                                                                                                   of availability of records                 - Trustwide Record Keeping audit is in progress to monitor
                                                                                                                                                                              implementation -updated raising the standards document PCT record
                                                                                                                                                                              keeping standards
                                                                                                                                                                              - Identified items arising from the Trustwide Record Keeping Audit,
                                                                                                                                                                              indicating where improvements can be made & support where further
                                                                                                                                                                              developments needed
                                                                                                                                                                              - Maintained mandatory Record keeping training, reviewing content
                                                                                                                                                                              annually- Coordinate & review record keeping in the Trust
                                                                                                                                                                              - Provided timely reports on Record Keeping activity with the PCT
                                                                                                          C9                                                                  - Ensured effective risk management and control measures are in
                                                                                                         C13b?                                                                place within all of the business units.
                                                                                                         C13c                                                                 - Reviewed the clinical governance structure and make
                                                                                                                                                                              recommendations for change.
                                                                                                                                                                              - Provided strong clinical leadership and clinical engagement to all of
                                                                                                                                                                              the business units.
                                                                                                                                                                              - Participated in the annual audit cycle in order to monitor
                                                                                                                                                                              standard/provision of care
                                                                                                                                                                              - Reviewed current clinical supervision practice and make
                                                                                                                                                                              recommendations to achieve minimum standards.
                                                                                                                                                                              - Led the role out of the essence of care benchmarking topics across
                                                                                                                                                                              all business units.
                                                                                                                                                                              - Implemented ‘dignity workbook’ with all practitioners within inpatient
                                                                                                                                                                              areas.
                                                                                                                                                                              - Developed new website for essence of care.
                                                                                                                                                                              - Monitored progress by infection control team against work
                                                                                                                                                                              programme and associated action plans.




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Objective Number




                                                                                            Care Services
 Business Unit




                                                                            Lead Director




                                                                                                                       Risk Number




                                                                                                                                                                                                                                                                       Traffic Light




                                                                                                                                                                                                                                                                                                                                                                                        Traffic Light
                                                                                                                                                                                                                                          Risk Rating




                                                                                                                                                                                                                                                                                                                                                         Risk Rating
                                                                                                            Mapped                                                                                                                                                                                                                                                     Residual Risk                     Assurance - External             Internal Management                                  Gaps in
                              DIRECTORATE OBJECTIVE                                                                                             RISK                                           Existing Controls                                        Risk Rating                                         Planned Controls                                                                                                                                          Gaps In Control
                                                                                                            to HCS                                                                                                                                                                                                                                                        Rating                          (inc Internal Audit)                 Assurance                                      Assurance



OD1                Commence development of the new Operational              KT               Y                       OD1.1 Failure of Operational Business Units to - Business unit formally agreed                                            9          #REF!       #REF!            - Determine the purpose, function, core business and                   6           #REF!        #REF!            - HCS C5a                     - Quarterly monitoring of       No                No
                   Business Units to enable them to operate as                                                        (CS) operate as stand alone businesses        - Individual Business Plans                                                                                        management arrangements for the Units                                                                                                          Business Plans
                   standalone businesses                                                                                                                            - Activity performance and budgetary targets                                                                       - Performance manage the Business Units to determine the                                                                                       - Monthly Budgetary and
                                                                                                             C5a                                                    - Support Service developing there report mechanisms in line                                                       activity delivered, quality outcomes and financial standing                                                                                    activity monitoring reports t0o
                                                                                                             C6                                                     with new Business Units                                                                                            - To explore and develop business opportunities to support                                                                                     joint management team OMG
                                                                                                             C7d                                                                                                                                                                       organisational growth within the units                                                                                                         and Care Services Board
                                                                                                             D2                                                                                                                                                                        - Ensure managers actively participate in the IT                                                                                               - HCS C6
                                                                                                                                                                                                                                                                                       infrastructure project including replacement of the TCS
                                                                                                                                                                                                                                                                                       system
OD2                Ensure financial viability of the Operational Business   KT               Y                       OD2.1 Poor budgetary control resulting in           - Financial management system in place across all Business            9          #REF!       #REF!            - Ensure proactive involvement in key commissioning
                                                                                                                                                                                                                                                                                       - Achieve financial balance including the agreed vacancy               6           #REF!        #REF!             - HCS C7d - ALE           - Monthly budget and activity No                     No
                   Units                                                                                              (CS) failure to achieve financial balance for      units                                                                                                         factor and Cost Reduction Programme                                                                              - Internal Audit 07/08 Ref monitoring reports to joint
                                                                                                                           the Operational Business Units                                                                                                                              - Ensure all relevant financial controls are applied across all                                                  3 - Budgetary Control      management team, OMG and
                                                                                                             C7d                                                                                                                                                                       business units.                                                                                                                             care services board




HR7                To ensure the PCT meets its Health and Safety            GM               Y                       HR7.1 - Harm/damage occurs to                       - Trustwide & local Health & Safety Committees                        9          #REF!       #REF!            - To review existing systems & processes to ensure health              6           #REF!        #REF!            - Staff Survey Results        - H&S objectives/           No                    No
                   obligations and priorities.                                                                        (CS) patients/staff/visitors/property failure to   - Health & Safety Policy & procedures                                                                         & Safety Auditing and monitoring is robust                                                                       - internal audit report ref   performance indicators
                                                                                                                           meet statutory requirements through           - Competent Advisors/H&S Team                                                                                 - To produce & deliver a plan to improve engagements &                                                           06/07 11 risk                 monitored via the PCT H&S
                                                                                                                           failure of the PCT to minimise health,        - Health & Safety/Risk Assessment Manuals                                                                     communications between the Health & Safety Team &                                                                management                    Committee & reported to the
                                                                                                                           safety and environmental risks. Non           - Health & Safety Key Objectives/Performance Indicators                                                       Operational Services                                                                                             - C7c, C20a                   Risk Management Committee
                                                                                                                           compliance with Health & Safety               - Controls assurance risk register & action plan                                                              - Improve links with Risk Management Team                                                                                                      - H&S Indicators reported
                                                                                                            C4 all         regulations                                   - Incident Trend monitoring                                                                                   - Review of Incident Reporting                                                                                                                 Board quarterly
                                                                                                             C7c                                                         - Mandatory training policy                                                                                   - To progress and implement the Lone Worker.
                                                                                                            C20a                                                         - Annual health & safety/Security report to PCT Board                                                         - To agree a Fire Safety Policy for the PCT which reflect
                                                                                                             D1                                                          - Implemented PCT Security Strategy & Associated action plan                                                  recent changes in legislation.
                                                                                                            D12a                                                         - Provided appropriate advice in respect of LIFT new builds &                                                 - To implement new Health and Safety Training
                                                                                                            D12b                                                         development of Mental Health Unit
                                                                                                                                                                         - Reviewed Health and Safety Training within the PCT




HR2                To lead on the HR Workstream of the PCT in relation GM                    Y                       HR2.2 The risk of TUPE regulations being       - Staff management agreement (implemented)                                 9          #REF!       #REF!            - Staff Management Agreement                                           9           #REF!        #REF!            - HCS C11a                                                    No                Yes -
                   to the Provider Project.                                                                 C7d,      (CS) found to have occurred in partnership in - Agreement with trade unions                                                                                      - Partnership Workforce Dev Group.                                                                                                                                                               Unquantified risk
                                                                                                            D5a,           action
                                                                                                            C10a,
                                                                                                            C10b,
                                                                                                            C11a,
                                                                                                            C11b,
                                                                                                            C11c

HR2                To lead on the HR Workstream of the PCT in relation GM                    Y                       HR2.1 - Lack of staff engagement.               -Annual Training Plan                                                     9          #REF!       #REF!            - Raise awareness at Board level of staff capacity issues &            9           #REF!        #REF!            - Strategic Health            - Annual training plan to OMG   - Capacity         No
                   to the Provider Project.                                                                           (CS) Organisation unable to retain and recruit - Locality Training Plan                                                                                          impact on attendance                                                                                             Authority                     provider                        issues for staff
                                                                                                                           staff.                                    - HR indicators                                                                                                   - Work with service managers, Modernisation Directorate &                                                        -Staff Survey Results         - Care Services Board           to attend training
                                                                                                             C5c                                                     - KSF Implemented                                                                                                 staff to produce a draft strategy for consultation covering                                                      - IWL Practice Plus           monitors uptake staff           - Diminishing
                                                                                                             C7e                                                     - Internal Communication strategy                                                                                 such aspects as Leadership Development; Support for                                                              Status achieved 2006          development reviews             funding from
                                                                                                             C8b                                                     - to review how staff of the PCT can be engaged in the project.                                                   Change; Learning & Development; Staff Involvement;                                                               - HCS C11a                    - HCS C10a, C11b                SHA
                                                                                                             C10a                                                    - Identified the HR issues which will inform the governance                                                       Recruitment & Selection; HR Skills for Managers
                                                                                                             C10b                                                    arrangements                                                                                                      - To establish an HR workstream and plan.
                                                                                                             C11a                                                                                                                                                                      - To lead on the implementation of the plan within the PCT.
                                                                                                             C11b
                                                                                                             C11c
                                                                                                             D5a
                                                                                                              D7



HR1                To produce an HR Strategy which will support the         GM               Y                       HR1.2 Failure of the PCT to support staff in        - Management of Ill Health Policy                                     9          #REF!       #REF!            - Complete Research project into Workplace Wellbeing in                6           #REF!        #REF!            - IWL Practice Plus           - Monitored as part of IWL      No                No
                   reconfiguration of the PCT to reflect the split                                                    (CS) health and well being at work resulting in    - Manager reports on sickness                                                                                 conjunction with Sheffield University                                                                            status achieved 2006          work
                   between Care Services and Commissioning                                                                 absence from work due to ill                  - HR Indicators                                                                                               - Revised management guidance & training                                                                         - Staff Survey results        - JMSC Monitor sickness
                   functions                                                                                               health/sickness affecting the ability of      - IWL Group                                                                                                   - Improved HR Reporting                                                                                          - HSE Inspections             absence indicators
                                                                                                                           the PCT to provide services efficiently       - Staff Support Services                                                                                      - Produce an outline plan for the Care Services Board                                                                                          - HR indicators to Care
                                                                                                             C7e           and safely                                    - Family Friendly Policies                                                                                    - Consult on the plan throughout the PCT.                                                                                                      Services Board as part of
                                                                                                             D7                                                          - Occupational Health Services                                                                                - Produce final HR strategy                                                                                                                    Care Services Performance
                                                                                                                                                                         - Back Care Advisor                                                                                                                                                                                                                                          Management Report
                                                                                                                                                                         - FIMS Returns



HR1                To produce an HR Strategy which will support the         GM               Y                       HR1.1 - Lack of staff engagement.                   -Annual Training Plan                                                 9          #REF!       #REF!            - Raise awareness at Board level of staff capacity issues &            9           #REF!        #REF!            - Strategic Health            - Annual training plan to OMG   - Capacity         No
                   reconfiguration of the PCT to reflect the split                                                    (CS) Organisation does not have the                - Locality Training Plan                                                                                      impact on attendance                                                                                             Authority                     provider                        issues for staff
                   between Care Services and Commissioning                                                   C5c           workforce with the right skills and in the    - HR indicators                                                                                               - Work with service managers, Modernisation Directorate &                                                        -Staff Survey Results         - Board monitors uptake staff   to attend training
                   functions                                                                                 C7e           right numbers to achieve its objectives.      - KSF Implemented                                                                                             staff to produce a draft strategy for consultation covering                                                      - IWL Practice Plus           development reviews             - Diminishing
                                                                                                             C8b                                                         - Internal Communication Strategy                                                                             such aspects as Leadership Development Support for                                                               Status achieved 2006          - HCS C10a, C11b                funding from
                                                                                                             C10a                                                                                                                                                                      Change; Learning & Development; Staff Involvement;                                                               - HCS C5c, C8b, C11a          - HR reports to Care Services   SHA
                                                                                                             C10b                                                                                                                                                                      Recruitment & Selection; HR Skills for Managers                                                                                                board
                                                                                                             C11a                                                                                                                                                                      - Produce an outline plan for the Care Services Board
                                                                                                             C11b                                                                                                                                                                      - Consult on the plan throughout the PCT.
                                                                                                             C11c                                                                                                                                                                      - Produce final HR strategy
                                                                                                             D5a
                                                                                                              D7




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                                                                                                                                                                                                                                      CARE SERVICES ASSURANCE FRAMEWORK




Objective Number




                                                                                        Care Services
 Business Unit




                                                                        Lead Director




                                                                                                                   Risk Number




                                                                                                                                                                                                                                                                                         Traffic Light




                                                                                                                                                                                                                                                                                                                                                                                                      Traffic Light
                                                                                                                                                                                                                                                            Risk Rating




                                                                                                                                                                                                                                                                                                                                                                       Risk Rating
                                                                                                        Mapped                                                                                                                                                                                                                                                                       Residual Risk                     Assurance - External              Internal Management                               Gaps in
                              DIRECTORATE OBJECTIVE                                                                                                RISK                                                Existing Controls                                                  Risk Rating                                         Planned Controls                                                                                                                                     Gaps In Control
                                                                                                        to HCS                                                                                                                                                                                                                                                                          Rating                          (inc Internal Audit)                  Assurance                                   Assurance



PQ3                Ensure equality and diversity is part of the PCT’s   SB               Y                       PQ 3.3 Non      compliance      with    legislative        Clinical Audit:                                                                      9          #REF!       #REF!            - Ensure that the PCT meets it legal requirements in terms         6           #REF!        #REF!             - HCS C7e, C18                - Equality indicator report to No               No
                   core business across all its functions/activities.                                             (CS) requirements in relation to equality and             - Service Level Agreement for Clinical Audit                                                                                 of equality and diversity and the general duty through the                                                   - Disability 2 tick symbol -   Diversity Steering Group
                                                                                                                                                                            - Discussion at care groups
                                                                                                                        diversity ensuring it is part of the PCTs           - Topic identification tool
                                                                                                                                                                                                                                                                                                         monitoring of the action plans for Race, Disability and                                                      positive about disabled        - Diversity Statement In PCT
                                                                                                                        core business                                       Evaluation/Research                                                                                                          Gender Equality                                                                                              people                         Annual Report
                                                                                                                                                                            - Research Governance Sub Group - revise research proposals                                                                  - Ensure compliance with internal and external assessment                                                                                   - Equality and Diversity
                                                                                                                                                                            - Research Alliance                                                                                                          processes                                                                                                                                   Steering Group minutes to the
                                                                                                                                                                            - LREC                                                                                                                       - Ensure that contracts and service level agreements cover                                                                                  Board
                                                                                                                                                                            - Maintained a system for the receipt of external alert notifications and
                                                                                                                                                                            processes for distribution and the monitoring of returns
                                                                                                                                                                                                                                                                                                         equality and diversity issues                                                                                                               - HCS C14b
                                                                                                                                                                            - Director lead for Equality                                                                                                 - Work towards developing a Single Equality Scheme
                                                                                                         C5a
                                                                                                                                                                            - Diversity Steering Group                                                                                                   - To develop a Clinical Audit Strategy
                                                                                                         C7e
                                                                                                                                                                            - Programme of work and action plan                                                                                          - To develop a Clinical Audit Policy
                                                                                                         C11a                                                               - Produced a job description and person specification for a PCT wide
                                                                                                         C13a                                                               Equality and Diversity Advisor
                                                                                                         C14a                                                               - Submitted job description and person specification for banding to the
                                                                                                         C15a                                                               Agenda for Change Office
                                                                                                                                                                            - Produced a business case and submit to the LDP process to secure
                                                                                                         C16                                                                funding for the Equality and Diversity Advisor post
                                                                                                         C17                                                                - Reconfigured the PCT’s Diversity Group at a strategic level to develop and
                                                                                                         C18                                                                lead the equality and diversity work across the organisation
                                                                                                         C23                                                                - Revised the terms of reference/membership for the PCT’s Diversity Group
                                                                                                                                                                            - Reviewed Clinical Audit support within the PCT, in relation to the Care
                                                                                                                                                                            Services
                                                                                                                                                                            - Reviewed and Developed Clinical Audit Training and guidance for Care
                                                                                                                                                                            Services
                                                                                                                                                                            - Ensured a robust Clinical Audit schedule with agreed timescales
                                                                                                                                                                            - Ensured there are systems in place for monitoring the delivery of the audit
                                                                                                                                                                            schedule and ensuring that action plans are implemented
                                                                                                                                                                            - Implemented an effective storage system of relevant electronic and paper
                                                                                                                                                                            documents to fulfil the requirements for retention of information for the
                                                                                                                                                                            Freedom of Information Act and Data Protection Act
                                                                                                                                                                            - Developed a reporting database for all audit projects and produce an
PH8                Health protection through effective        emergency PR               Y                       PH8.1 - PCT unprepared to respond to major                 - SYSHA Major Incident & Communication Plan (i)                                      9          #REF!       #REF!            - Programme of training on & testing of major incident plan        9           #REF!        #REF!            - Fit for Purpose review       - Table Top Emergency         No                No
                   planning and partnership working                                                               (CS) incidents or disease outbreaks                       - SY Health Emergency Planning Forum                                                                                         developed & implemented                                                                                      and action plan                Planning exercise PAMBO
                                                                                                                                                                            - SY Integrated Emergncy Response Plan for Health Protection                                                                 - Await report of outcome of training & testing                                                              - Additional District Audit    July 07
                                                                                                                                                                            Incidents/Outbreaks                                                                                                          - Review major incident plan, flu plan, heatwave plan and                                                    assurance 2007                 - LIVE exercise PAMBO
                                                                                                                                                                            - Programme of testing of major incident plan with partner                                                                   CBRN plans                                                                                                                                  planned 06 September 07
                                                                                                                                                                            agencies                                                                                                                     - Undertake exercises in line with guidance                                                                                                 - HCS C24
                                                                                                                                                                            - Public Health Business ImpactAnalysis & Continuity Plan                                                                    - Participate in South Yorkshire Emergency Planning Forum
                                                                                                                                                                            templates                                                                                                                    meetings and training
                                                                                                                                                                            - PCT Major Incident Plan developed with partner agencies                                                                    - Convene PCT Emergency Planning Group
                                                                                                                                                                            - Consultant in communicable disease control                                                                                 - Respond to IPPC consultations within required
                                                                                                                                                                            - Health Protection Nurse Specialist                                                                                         - With SYPH network re-negotiate memorandum of
                                                                                                                                                                            - Major Incident Plan incorporates outbreak plan                                                                             understanding with HPU
                                                                                                                                                                            - Control of Infection Committee                                                                                             - Contribute to South Yorkshire’s on-call rota
                                                                                                         C24
                                                                                                                                                                            - South Yorkshire Health Protection Agency                                                                                   - Review communications and set up intranet web page
                                                                                                         D13c
                                                                                                                                                                            - Participate in South Yorkshire Emergency Planning Forum
                                                                                                                                                                            meetings & training
                                                                                                                                                                            - PCT Emergency Planning Group
                                                                                                                                                                            - Contribute to South Yorkshire's on-call rota
                                                                                                                                                                            - PCT Emergency Planning Group to include representatives
                                                                                                                                                                            from wider health community as well as BMBC
                                                                                                                                                                            - Develop contingency planning with provider arm PCT -
                                                                                                                                                                            programme regular simulation events in line with major
                                                                                                                                                                            incident plan
                                                                                                                                                                            - Developed training programme in emergency planning
                                                                                                                                                                            - Reviewed communications and set up intranet web page


  Fi2              To contribute to the effective control of and SH                      Y                        Fi2.2           Fraudulent use of NHS                     - Anti Fraud Policy                                                                  6          #REF!       #REF!            - To support the work in relation to Yorkshire and Humber          6           #REF!        #REF!            - Internal Audit/Counter       - Audit Committee             No                No
                   achievement of financial statutory duties                                                      (CS)           resources/corruptive decision making       - Code of Conduct on openness & Accountability                                                                               Commercial Procurement to maximise benefits driven from                                                      Fraud & Security reports       - Local counter fraud
                                                                                                                                 arising from failure to promote            - Standing Order                                                                                                             aggregated purchasing                                                                                        to Audit Committee             specialist internal work
                                                                                                                                 openness, honesty, probity,                - Scheme of Delegation                                                                                                       - To investigate value for money opportunities through its                                                   - ALE C7d                      programme
                                                                                                                                 accountability & economic, efficient &     - Hospitality Policy                                                                                                         commercial procurement strategies
                                                                                                                                 effective use of resources.                - Awareness sessions for staff on counter fraud                                                                              - To Produce robust forecasts on income and expenditure
                                                                                                                                                                            - Whistleblowing Policy                                                                                                      on a monthly basis
                                                                                                                                                                            - Communicated via intranet site on Fraud
                                                                                                                                                                            - Supported the development of cost improvement
                                                                                                                                                                            programmes and saving schemes in consultation with budget
                                                                                                                                                                            holders
                                                                                                         C7d
                                                                                                                                                                            - Supported the Commissioning Directorate in the production
                                                                                                         C7f
                                                                                                                                                                            of the Local Delivery Plan and ongoing monitoring, including
                                                                                                                                                                            submissions to the Strategic Health Authority
                                                                                                                                                                            - Performance managed the organisation in respect of its
                                                                                                                                                                            statutory financial requirements
                                                                                                                                                                            - LCFS in post
                                                                                                                                                                            - Fraud Policy in place
                                                                                                                                                                            - Workshops with Senior Managers
                                                                                                                                                                            - Induction workshops
                                                                                                                                                                            - Fraud awareness sessions with Team
                                                                                                                                                                            - Fraud plan and programme of work in place


  Fi3              To enhance the financial information provided to SH                   Y                        Fi3.2          - Failure to identify spends over budget   - Contracts meetings                                                                 6          #REF!       #REF!            - To develop web based budgeting and purchase order                6           #REF!        #REF!            - Assurance re Financial                                     No                No
                   budget holders to aid efficient and effective decision                                         (CS)           particularly for cost per case & out of    - Regular Reports & Invoices                                                                                                 processing elements within the system                                                                        decision making
                   making                                                                                                        district spends                            - LPCO's & Client Boards (Out of District & Continuing Care)                                                                 - To ensure that budget holders have received sufficient                                                     - Budget Reporting,
                                                                                                                                                                            - Management accountant budget monitoring                                                                                    training to effectively use the new financial system                                                         Monitoring & Board
                                                                                                                                                                            - Monthly financial monitoring report                                                                                        - To explore the opportunities for investing in a service                                                    Reporting 2006/07
                                                                                                                                                                            - Completed the implementation of the new financial systems                                                                  costing system in relation to the provider arm.                                                              - ALE C7d
                                                                                                                                                                                                                                                                                                                                                                                                                      - Creditors & Supplies
                                                                                                                                                                                                                                                                                                                                                                                                                      Procedures Strategy July
                                                                                                         C7d                                                                                                                                                                                                                                                                                                          2005
                                                                                                         C7f                                                                                                                                                                                                                                                                                                          - Income & Debtors June
                                                                                                                                                                                                                                                                                                                                                                                                                      2005
                                                                                                                                                                                                                                                                                                                                                                                                                      - Internal Audit Report
                                                                                                                                                                                                                                                                                                                                                                                                                      06/07 Budgetary Control




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Objective Number




                                                                                          Care Services
 Business Unit




                                                                          Lead Director




                                                                                                                     Risk Number




                                                                                                                                                                                                                                                                            Traffic Light




                                                                                                                                                                                                                                                                                                                                                                                              Traffic Light
                                                                                                                                                                                                                                               Risk Rating




                                                                                                                                                                                                                                                                                                                                                            Risk Rating
                                                                                                          Mapped                                                                                                                                                                                                                                                          Residual Risk                        Assurance - External             Internal Management                                 Gaps in
                              DIRECTORATE OBJECTIVE                                                                                                 RISK                                            Existing Controls                                        Risk Rating                                         Planned Controls                                                                                                                                           Gaps In Control
                                                                                                          to HCS                                                                                                                                                                                                                                                             Rating                             (inc Internal Audit)                 Assurance                                     Assurance



 Fa1               Ensure current facilities meet the national guidance NM                 Y                       Fa1.2           - The PCT fails to meet national          - Nutritional analysis (by dietetic department) every 2 years          6          #REF!       #REF!            - external review of serivce by consultants                          3           #REF!          #REF!             - External PEAT               - Partnership site for Better No                  No
                   & legislation & all new facilities are designed to                                                              requirements set out in Better Hospital   when patient menus change                                                                                      - Produce a strategic Cleaning Plan                                                                               Validated at Kendray          Hospital Food at Keresforth &
                   promote effective care & optimise health outcomes                                                               Food in terms of choice & the provision   - Monitoring of Better Hospital Food action plans                                                              -Ensure regular monitoring and reporting against the plan                                                         - HCS C15a, C15b              Kendray
                                                                                                                                   of balanced diets with the knock on       - Introduction of computerised system for nutricial analysis                                                   -Produce annual customer satisfaction surveys for Facilities                                                                                    - Customer Surveys
                                                                                                                                   effect that the PCT fails to meet         -PEAT inspections are carried out and reported to the Care                                                     Services
                                                                                                                                   patient's nutritional requirements        Services Board                                                                                                 -Produce a Trust Food Waste Policy, and ensure that an
                                                                                                                                                                             - Produce an annual board report on the main kitchen                                                           annual report is produced for the board
                                                                                                                                                                             inspections and ensure a monitoring programme is in place, in                                                  - Continuation of recommendations after Catering Audit
                                                                                                                                                                             accordance with current Environmental Health legislation
                                                                                                           C15a                                                              - Produce an annual catering report to ensure the six criteria
                                                                                                           C15b                                                              for Better Hospital Food Programme are in place, and ensure a
                                                                                                                                                                             programme is in place to monitor the standards
                                                                                                                                                                             - Catering Audit




OD4                Develop responsive and meaningful workforce            KT               Y                       OD4.1 Poorly in-equipped staff in terms of skills         - Training Plans                                                       6          #REF!       #REF!            - Ensure staff training needs are clearly identified in PDP’s        3           #REF!          #REF!             - HCS C11a, C11c              - Reports on mandatory          No                No
                   planning within the Operational Business Units                                                   (CS) and resources that will compromise                  - SDRs                                                                                                         to ensure appropriate development of staff                                                                                                      training targets and SDRs
                                                                                                                         patient safety and business                         - PCT Workforce Plan                                                                                           - Ensure that all mandatory training targets are achieved                                                                                       - HCS C11b
                                                                                                                         development opportunities                           - Skill Mix Reviews                                                                                            - Ensure SDR and KSF processes are effectively
                                                                                                                         for the Operational Business Units                  - Mandatory Training Targets                                                                                   implemented
                                                                                                           C10
                                                                                                                                                                             - Training prioritised by Directors
                                                                                                           C11




OD5                To engage representative service users in service      KT               Y                       OD5.1 Inappropriate service development and               - Active involvement with ARENA                                        6          #REF!       #REF!            - Actively engage service users in the business units                3           #REF!          #REF!             - HCS C18                     - PEAT                           No               No
                   delivery and service monitoring in order to ensure                                      C6       (CS) reduction in patient choice through lack            - Provider meetings by Client groups with service users and                                                    development programme                                                                                                                           - Action plans following patient
                   equitable and access service development in                                             C13           of involvement of service users in the              carers                                                                                                                                                                                                                                                         satifaction surveys
                   Operational Business Units                                                              C14           Operational Business Units.                                                                                                                                                                                                                                                                                        - HCS C6, C14a, C17, C19
                                                                                                           C15
                                                                                                           C16
                                                                                                           C17
                                                                                                           C18
                                                                                                           C19

HR3                To commence development of the HR Directorate as GM                     Y                       HR3.1 Inefficient, ineffective HR directorate             - Staff Survey                                                         6          #REF!       #REF!            - Review key processes involved in order to set service              6           #REF!          #REF!             - Results of Healthcare       - HR Board Report               No                Yes - to improve
                   a potential business unit                                                                        (CS) which is not financially viable.                    - Informal Benchmarking                                                                                        standards                                                                                                         Standards C10a, C11a          - Provider Performance                            Benchmarking
                                                                                                                                                                             - HR Board Reports (performance)                                                                               - Undertake detailed costing work.                                                                                - Internal Audit reports on   Management Report to Care
                                                                                                                                                                             - Identify specific functions within the business unit                                                         - Agree SLA with Commissioner                                                                                     Payroll/HR Systems i.e.       Services Board
                                                                                                                                                                             - Identify potential 'produce lines'.                                                                                                                                                                                            ESR                           - HCS C11b
                                                                                                                                                                             - Work with Director of Service Improvement and Business
                                                                                                                                                                             Development to market at least 1 service externally.




HR4                To implement the Internal Communications Strategy      GM               Y                       HR4.1 - Failure to communicate with and        - Staff Survey Action Plan                                                        6          #REF!       #REF!            - Redesign the order of the monthly team Brief to make it            6           #REF!          #REF!             - IWL Practice Plus 2006 - Monitored as part of IWL           No                Yes
                                                                                                                    (CS) engage interest and involvement of staff - Staff charter                                                                                                           easier to deliver & digest                                                                                        - Staff Survey Results   work
                                                                                                                         resulting in lack of commitment by       - Communication Strategy                                                                                                  - Redevelop internal extranet & external website to reflect
                                                                                                                         employees to the organisation            - Individual/team/departmental meetings                                                                                   content that is needed by managers & requested by staff
                                                                                                                                                                  - PCT Newsletter                                                                                                          - Look at success of delivery methods of communications
                                                                                                                                                                  - Team Brief                                                                                                              eg notice boards, newsletter & develop a structured system
                                                                                                                                                                  - Publications PCT Mission & Goals                                                                                        to ensure they are up to date, timely available & useful to
                                                                                                                                                                  - Communications Group (internal & External)                                                                              staff
                                                                                                                                                                  - Staff Communication and Action Group                                                                                    - Use staff consultation effectively to assess the views &
                                                                                                                                                                  - implemented the action plan within the Internal                                                                         opinions of staff on issues that affect their working lives
                                                                                                           D7
                                                                                                                                                                  Communications Strategy as detailed within the Strategy                                                                   - Work with staff side representatives & IWL Group to
                                                                                                                                                                                                                                                                                            monitor the effectiveness of all communications with staff
                                                                                                                                                                                                                                                                                            - To implement he PCT's Internal Communications Strategy
                                                                                                                                                                                                                                                                                            - Review HR Strategy
                                                                                                                                                                                                                                                                                            - Electronic Comms Strategy
                                                                                                                                                                                                                                                                                            - Development of external website




  IS8              Modernise the existing PCT Infrastructure with a fit   SH               Y                       IS8.3           Organisation unable to attract and retain - Approved Infrastructure Deployment Plan for 2007/08 -                3          #REF!       #REF!            - Continual assessments of deployment plan for 2007/08               3           #REF!        Green                                             - PRINCE Project monitored      No                No
                   for Purpose Infrastructure                                                                       (CS)           staff                                     aligned to other Business Objectives                                                                           against business objectives                                                                                                                     by Mpfit Board
                                                                                                            D6                                                               - Approved allocation of capital funding required for second                                                   - Implementation of IT equipment replacement programme
                                                                                                           C8a                                                               Phase of the project                                                                                           - Implementation and monitoring of additional power and
                                                                                                           C8b                                                               - Redevelopment of Intranet site                                                                               networking based on site specific requirements against plan
                                                                                                           C11c                                                               -Tendered for additional power/network sockets contract(s)
                                                                                                           D5A
                                                                                                            D7


  Fi1              To ensure the production of financial information SH                    Y                       Fi1.2           - Failure to agree budget at              - Budget setting process locally & with SHA to ensure timely           3          #REF!       #REF!            - To provide comprehensive information regarding activity            3           #REF!          #REF!             - Budget Setting process                                      No                No
                   appropriate accurate and timely                                                                 (CS)            commencement of financial year            sign off of LDP                                                                                                costs in relation to payment by results to aid                                                                    with SHA
                                                                                                                                                                             - Produced monthly Board reports in line with local and                                                        - In consultation with budget managers produce robust                                                             - ALE - C7d
                                                                                                                                                                             national best practice                                                                                         forecasts to underpin internal and external reporting                                                             - internal audit report
                                                                                                           C7d                                                                                                                                                                              - Produced external returns for the public and Strategic                                                          06/07 r ref 3 Budgetary
                                                                                                           C7f                                                                                                                                                                              Health Authority in line with relevant guidelines                                                                 control,




  Fi5              To further develop HR plans for the directorate SH                      Y                       Fi5.1           - Finance Department fails to be fit for - SDR                                                                   3          #REF!       #REF!            - To ensure staff appraisals are performed in accordance             3           #REF!          #REF!             - ALE - C7d                                                   No                No
                   ensuring that the directorate has the right skills and                                          (CS)            purpose                                  - Reviewed staffing structure in line with current service model                                                with HR policy                                                                                                    - District Audit letter
                   abilities to meet the PCTs objectives                                                                                                                    - Review & adopt current best practice                                                                          - To continue to promote work life balance opportunities &                                                        - Internal Audit reports
                                                                                                                                                                            - Promote training opportunities that meet the individuals, the                                                 improving working lives initiatives within the needs of the                                                       Financial Systems
                                                                                                            C7
                                                                                                                                                                            departments& the PCTs needs                                                                                     service
                                                                                                           C8a
                                                                                                                                                                            - Promote an environment that is fit for purpose & is consistant                                                - To Promote training opportunities that meet the individuals
                                                                                                           C8b
                                                                                                                                                                            with the PCT Health & Safety policies                                                                           and organisations needs.
                                                                                                           C10a
                                                                                                                                                                            - Continued to promote work life balance opportunities and                                                      - To Promote an environment that is fit for purpose and is
                                                                                                           C10b
                                                                                                                                                                            improving working lives initiatives within the needs of the                                                     consistent with the PCT Health and Safety policies
                                                                                                           C11a
                                                                                                                                                                            service
                                                                                                           C11b
                                                                                                                                                                            - Reviewed staffing levels in accordance with service demands
                                                                                                           C11c
                                                                                                                                                                            taking account of business risks and objectives




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                                                                                                                                                                                                                            CARE SERVICES ASSURANCE FRAMEWORK




Objective Number




                                                                                          Care Services
 Business Unit




                                                                          Lead Director




                                                                                                                     Risk Number




                                                                                                                                                                                                                                                                            Traffic Light




                                                                                                                                                                                                                                                                                                                                                                                             Traffic Light
                                                                                                                                                                                                                                               Risk Rating




                                                                                                                                                                                                                                                                                                                                                           Risk Rating
                                                                                                          Mapped                                                                                                                                                                                                                                                         Residual Risk                        Assurance - External          Internal Management                                 Gaps in
                              DIRECTORATE OBJECTIVE                                                                                                 RISK                                           Existing Controls                                         Risk Rating                                         Planned Controls                                                                                                                                       Gaps In Control
                                                                                                          to HCS                                                                                                                                                                                                                                                            Rating                             (inc Internal Audit)              Assurance                                     Assurance



PQ 7               Develop the planning process and integrate with the    SB               Y                       PQ 7.2 - Failure of the PCT to put in place              - Consideration of Assurance Framework by Governance                    3          #REF!       #REF!            - Completion of action plan following review of working of          3           #REF!          #REF!             - SHA approved             - Assurance Framework           No                No
                   assurance framework and risk register                                                            (CS) effective corporate governance systems             Committee                                                                                                       Audit Committee                                                                                                  Assurance Framework        considered by Audit
                                                                                                                          to regulate the business & ensure the             - Separate consideration of AF by Non-executive Directors                                                                                                                                                                        - Audit Commission         Committee
                                                                                                                          adequacy of the PCTs system of                    - Assurance Framework & associated Risk Register developed                                                                                                                                                                       approval for Assurance     - Assurance Framework
                                                                                                                          Internal Control                                  - System in place for identifying prinical risks from main                                                                                                                                                                       Framework                  submitted to the Board
                                                                                                                                                                            committee structures to add to AF                                                                                                                                                                                                - HoIA Statement Audit
                                                                                                           C7a                                                              - Facilitated the development of local plans supporting                                                                                                                                                                          Committee reviewed
                                                                                                           C7c                                                              business units as and when required.                                                                                                                                                                                             - Internal Audit
                                                                                                                                                                            - Ensured the Care Service Annual (Business) Plan is linked to                                                                                                                                                                   verification of PCT
                                                                                                                                                                            the Assurance Framework and strategic goals, objectives and                                                                                                                                                                      Assurance Framework
                                                                                                                                                                            Healthcare Standards                                                                                                                                                                                                             - Statement on Internal
                                                                                                                                                                                                                                                                                                                                                                                                             Control
                                                                                                                                                                                                                                                                                                                                                                                                             - ALE
                                                                                                                                                                                                                                                                                                                                                                                                             - HCS C7a, C7c

PQ 7               Develop the planning process and integrate with the    SB               Y                       PQ 7.1 - lack of Strategic direction and - Business Planning Training                                                            3          #REF!       #REF!            - Provide business planning training to PCT staff as                3           #REF!          #REF!             - Head of Internal Audit   - Business plan to the Care  No                   No
                   assurance framework and risk register                                                            (CS) business planning throughout the PCT - Business Planning Framework                                                                                                 appropriate.                                                                                                     Opinion Statement Audit    Services Board
                                                                                                                          to achieve its mission              - Support from Performance & Quality to Business Units to                                                                                                                                                                                      Committee reviewed         - Assurance Framework to the
                                                                                                                                                              develop Business Plans                                                                                                                                                                                                                         - Internal Audit           Audit Committee & Board
                                                                                                                                                              - Quarterly Performance Reviews                                                                                                                                                                                                                verification of PCT
                                                                                                                                                              - End of year reviews with Provider Business Units                                                                                                                                                                                             Assurance Framework
                                                                                                                                                              - Business planning guidance is refined & updated annually                                                                                                                                                                                     - HCS C7a, C7c
                                                                                                                                                              - Facilitated the development of service plans supporting the
                                                                                                                                                              business units as & when required
                                                                                                                                                              - Business planning training is available to PCT staff
                                                                                                           C7a                                                - Business plan is linked to the assurance framework
                                                                                                           C7c                                                - Submitted business plan for Board approval
                                                                                                                                                              - Facilitated the development of local plans supporting
                                                                                                                                                              business units as and when required.
                                                                                                                                                              - Ensured the Care Service Annual (Business) Plan is linked to
                                                                                                                                                              the Assurance Framework and strategic goals, objectives and
                                                                                                                                                              Healthcare Standards
                                                                                                                                                              - Submitted the Plan to the Care Services Board for approval




MD 1               To contribute to the development of quality services KW                 Y                       MD 1.1 Reduction in Clinical Performance and             - Consultants monitor the caseload                                      3          #REF!       #REF!            - Liaise with the Barnsley Foundation NHS Trust GUM                 3           #REF!          #REF!                                        - Annual appraisals and job     No                No
                   provided by the PCT                                   M                                          (CS) possible increase in out of area                   - Developed specialist service support                                                                          Service in order to integrate into the 48 hour access target                                                                                plan on all medical staff and
                                                                                                                          placements                                        - Developed Sexual Health Services and upgrade IT in the                                                        - To develop an external appraisal for medical staff                                                                                        GPs
                                                                                                                                                                            Family Planning Service
                                                                                                                                                                            - Developed a Medical Directorate Clinical Governance Plan
                                                                                                                                                                            - Implemented an Appraisal Policy for all Medical Staff
                                                                                                                                                                            employed in the PCT
                                                                                                                                                                            - Job Planning Policy for consultant medical staff
                                                                                                                                                                            - Developed the Care of the Elderly Service to improve
                                                                                                           D4a                                                              delivery of care and be more responsive to PCT Management
                                                                                                           D4b                                                               - Developed good prescribing within the PCT and ensure all
                                                                                                           D4c                                                              prescribing is appropriate inline with PCT Formulary
                                                                                                                                                                            - Developed a robust Clinical Governance Plan for the Medical
                                                                                                                                                                            Directorate
                                                                                                                                                                             - Developed an SLA for Eating Disorders with Yorkshire
                                                                                                                                                                            Centre for eating disorders in Leeds




  IS8              Modernise the existing PCT Infrastructure with a fit   SH               Y                       IS8.1           Organisation unable to attract and retain Approved Infrastructure Deployment Plan for 2007/08 -                  3          #REF!       #REF!                                                                                3           #REF!        Green                                          - PRINCE Project monitored      No                No
                   for Purpose Infrastructure                                                                       (CS)           staff                                     aligned to other Business Objectives                                                                                                                                                                                                                       by Mpfit Board
                                                                                                                                                                             - Approved allocation of capital funding required for second
                                                                                                                                                                             Phase of the project
                                                                                                                                                                             - Redevelopment of Intranet site
                                                                                                            D6                                                               - Tendered for additional power/network sockets contract's)
                                                                                                           C8a                                                               '- Continual assessments of deployment plan for 2007/08
                                                                                                           C8b                                                               against business objectives
                                                                                                           C11c                                                              - Implementation of IT equipment replacement programme
                                                                                                           D5A                                                               - Implementation and monitoring of additional power and
                                                                                                            D7                                                               networking based on site specific requirements against plan




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