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                                                                   RISK SCORING MATRIX

                         Likelihood of Risk                                       Consequence/severity
                                                 Insignificant            Minor (2)  Moderate (3)   Major (4)                        Catastrophic
                                                      (1)                                                                                 (5)
                         Rare (1)                      1                      2                    3                   4                   5
                         Unlikely (2)                  2                      4                    6                   8                  10
                         Possible (3)                  3                      6                    9                   12                 15
                         Likely (4)                    4                      8                    12                  16                 20
                         Almost Certain (5)            5                      10                   15                  20                 25



                         When the following Likelihood and Consequence are multiplied together, the scores give a
                                                 risk rating of between 1 and 25 on matrix.



                                                              LIKELIHOOD OF OCCURRENCE



                             Likelihood              Rating                             Description
                                Rare                   1               May occur only in exceptional circumstances
                               Unlikely                2               Event Unlikely to occur
                              Possible                 3               Reasonable chance of occurring
                                Likely                 4               Will occur in most circumstances
                           Almost Certain              5               Most likely to occur, than not




                                                  CONSEQUENCE SCORING - Injury / Death chart

                            Consequence               Rating                                       Description
                             Insignificant              1                  Minor impact injury which did not affect the person / Reduced
                                                                                   Organisational performance for than 1 week
                                 Minor                   2                    Minor Injury, first aid required / Reduced Organisational
                                                                                     performance, between 1 week and 1 month
                               Moderate                  3             Semi-permanent injury/damage lasting up to 1 year. An over 3-day
                                                                       staff injury reportable under RIDDOR. Litigation cost of £50,000 to
                                                                                £500,000. / Reduced performance up to one month
                                 Major                   4              Significant or permanent injury (loss of/use of limb. Major injury,
                                                                            reportable under RIDDOR, fractured neck of femur / High
                                                                       environmental implication / Litigation cost of £500,000 to £1million. /
                                                                          Temporary service closure. / low key national media coverage

                             Catastrophic                5             Unexpected death of a patient or member of staff. International
                                                                       adverse publicity/severe loss of confidence in the organisation.
                                                                       Extended service closure. Litigation cost greater than £100k /
                                                                       adverse high profile national media coverage


                                                 ACTION AND REPORTING REQUIREMENTS

                              Risk Level              Rating                         Actions                                Required Responsibility
                                                                       Managed through normal local             Local Actions –Managed by Line Manager /
                                 LOW                                   control measures.                        Team leader
                                                        1-3
                                (Green)                                Entered onto Service Risk                Head of Service informed and formal risk
                                                                       Register                                 assessment undertaken
                                                                       Review control measures         Head of Service (or equivalent) for senor
                                                                       through formal risk assessment. Management Action – responsible for
                             MODERATE                                                                  controlling and reducing risk as soon as
                                                        4-6                                            reasonably practicable.
                                (Yellow)
                                                                       Entered on Directorate Risk              Risk Assessment supplied to Assistant
                                                                       Register                                 Director and Risk Management

                                                                       Treatment plans to be developed, Assistant Director level Action - responsible
                                                                       implemented and monitored        for controlling risk and reducing risk as soon
                                 HIGH                                                                   a practicable.
                                                       8-12
                                                                       Entered onto Corporate Risk              Risk Assessment required and supplied to
                                (Amber)
                                                                       Register                                 the Executive Director and Risk Management


                                                                       Immediate Actions Required to Executive Director level action - required to
                                                                       reduce risk                   instigate immediate actions to reduce risk.
                               SERIOUS
                                                      15 - 25
                                 (Red)                                 Entered onto Corporate Risk              Action Plan required and supplied to the
                                                                       Register                                 Director of Corporate Development and
                                                                                                                Governance and Risk Manager



                                                                Other Consequence Scoring Matrix


                                                         1                     2                    3                  4                      5
                               Descriptor          Insignificant             Minor             Moderate              Major             Catastrophic
                          Objectives/ Projects   Insignificant cost    <5% over budget/    5-10% over           10-25% over         >25% over budget/
                                                 increase/schedule     schedule            budget/schedule      budget/schedule     schedule slippage.
                                                 slippage. Barely      slippage. Minor     slippage.            slippage. Failure   Doesn‟t meet
                                                 noticeable            reduction in        Reduction in         to meet secondary   primary objectives.
                                                 reduction in scope    quality/scope       scope or quality.    objectives.
                                                 or quality
                            Injury (Physical/    Minor injury not      Minor injury or    RIDDOR/Agency     Major injuries, or      Death or major
                             Psychological)      requiring first aid   illness, first aid reportable        long term               Permanent
                                                 or apparent injury.   treatment needed                     incapacity/             incapacity
                                                                                                            disability (loss of
                                                                                                            limb)
                           Patient Experience/   Unsatisfactory       Unsatisfactory     Mismanagement Serious                      Totally
                                Outcome          patient experience patient experience of patient care,     mismanagement           unsatisfactory
                                                 not directly related – readily resolved short term effects of patient care,        Patient outcome or
                                                 to patient care                         (less than a week) long term effects       experience
                                                                                                            (more than a
                                                                                                            week)
                          Complaints / Claims    Locally resolved     Justified          Below excess       Claim above             Multiple claims or
                                                 complaint            complaint          claim. Justified   excess level.           single major claim
                                                                      Peripheral to      complaint          Multiple justified
                                                                      clinical care      involving lack of  complaints.
                                                                                         appropriate care.
                           Service/ Business     Loss/interruption Loss/interruption Loss/interruption Loss/interruption            Permanent loss of
                              Interruption       >1 hour              >8 hours           >1 day             >1 week                 service or facility
                           HR/ Organisational    Short term low       Ongoing low        Late delivery of   Uncertain delivery      Non delivery of key
                             Development         staffing level       staffing level     key                of key                  objective/service
                                                                                         objective/service objective/service        due to lack of staff.
                                                                                         due to lack of     due to lack of
                                                                                         staff.             staff.
                              Staffing and       Temporarily          Reduces service Minor error due to Serious error due          Loss of key staff.
                              Competence         reduces service      quality            ineffective        to ineffective          Critical error due to
                                                 quality (< 1 day)                       training.          training                insufficient training
                                                                                         Ongoing unsafe
                                                                                         staffing level.
                                Financial        Small loss           Loss > 0.1% of     Loss > 0.25% of Loss > 0.5% of             Loss > 1% of
                                                                      budget             budget             budget                  budget
                            Inspection/ Audit    Minor                Recommendation Reduced rating.        Enforcement             Prosecution.
                                                 recommendations. s given.               Challenging        Action. Low rating.     Zero rating.
                                                 Minor non-           Non compliance     recommendations. Critical report.          Severely critical
                                                 compliance with      with standards     Non-compliance Major non-                  report.
                                                 standards                               with core          compliance with
                                                                                         standards          core standards.

                           Adverse Publicity/    Rumours               Local Media –       Local media –        National Media      National Media >3
                              Reputation                               short term. Minor   long Term.           <3 days             days.
                                                                       effect on staff     Significant effect                       MP Concern
                                                                       morale.             on staff morale.                         (questions in the
                                                                                                                                    House)




As of 11 November 2008                                                                                                                                       Page 1
            North East Essex PCT                                                                   Risk Register - TOP Risks


                                                                                                                                                                                    Risk     Risk
  Date          Risk           Risk                Risk                Risk                                                                                                                                  HCC
                                                                                                Risk Description                                   Latest Update                    level    level                            Review date
 Added          Type           Area                Name               Owner                                                                                                                               Standards
                                                                                                                                                                                  (current (Target)
5-Jan-09     Assurance & Provider &    Incident Analysis Group -       JH     Since January 08, the IAG have undertaken three            LW advised that a new process has now
             Operational Commissioning Lack of assurances on                  workshops, reviewing incident data and significant events. been set up, lead by JH who will address
             Safety                    findings and                           All have producing a number of jointly agreed              the various IAG Recommendations
                                       recommendations                        recommendations and Healthcare Quality have worked with                                             SERIOUS                Safety & Clinical
                                                                                                                                                                                               LOW                             16-Jan-2009
                                                                              Provider Services, but Commissioning have not yet                                                   Level 15                Effectiveness
                                                                              managed to confirm what recommendations have been
                                                                              taken and the IGC felt this to be a significant risk.

5-Jan-09     Assurance    Provider &    Safety Alert -                 MT     lack of assurance on compliance - exceeded DoH deadline   MT verbally advised that she is
                          Commissioning NICE/NPSA/2007/PSG001                 of 12 December 2008                                       progressing this and feels that the PCT
                                        Technical patient safety              * Alert issued in December 2007                           is approx 80% compliant
                                        solutions for medicines                                                                                                                   SERIOUS                Safety & Clinical
                                        reconciliation on admission                                                                                                                            LOW                             16-Jan-2009
                                                                                                                                                                                  Level 15                Effectiveness
                                        of adults to hospital



11-Sep-08    Assurance    Provider &    Safety Alert - DH (2008)      MT/LW   lack of assurance on compliance - exceeded DoH deadline   LW advised she has met with MT to
                          Commissioning 05, Patient Weighing                  of July 2008                                              progress. The relevance of the alert to
                                                                                                                                                                                  SERIOUS                Safety & Clinical
                                        Scales                                                                                          the PCT is minimum, however MT is                      LOW                             16-Jan-2009
                                                                                                                                                                                  Level 15                Effectiveness
                                                                                                                                        expected to formally conclude.

8-Jun-08     Assurance    Provider &    Safety Alert NPSA/2007/20      MT     lack of assurance on compliance - exceeded DoH deadline   No update supplied. However MT
                          Commissioning - Promoting Safer Use of              of 31 March 08                                            previously advised that she has worked
                                        Injectable Medicines                                                                            on this alert with CHUFT and presented
                                                                                                                                                                                  SERIOUS      LOW       Safety & Clinical
                                                                                                                                        the issue to their Medicines Safety                                                    16-Jan-2009
                                                                                                                                                                                  Level 15   Level 1-3    Effectiveness
                                                                                                                                        Group. MT Feels compliance to the
                                                                                                                                        alert will be achieved in Jan 09.

2-Apr-08     Operational - Provider &    Loneworker Protection -       LW     In 2005, as part of a trial, the PCT issued a limited number Order now placed and PCT
             Safety        Commissioning personal alarm devices               of personal alarm devices, designed to be linked to a        implementation due to commence in Jan
                                                                              monitoring station to a small amount of Tendering staff.     09.
                                                                              Until now this trial was not followed up or concluded. There
                                                                              will always be a degree of personal safety risk associated
                                                                              with lone workers in the community, therefore the provision                                        SERIOUS       LOW       Safety & Clinical
                                                                                                                                                                                                                               31-Mar-2009
                                                                              of devices which use mobile phone technology can enhance                                           Level 15    Level 1-3    Effectiveness
                                                                              the personal security of staff and help to reduce individual
                                                                              fear of crime.



22-Oct-08    Compliance   Provider &    SUI - LD POVA                  FG     Historical (March 06) LD POVA SUI                         ECC have now successfully engaged
                          Commissioning                                                                                                 with FG and ECC have now completed
                                                                                                                                        and forwarded a SETSAF4 form. This
                                                                                                                                        highlights the principal actions taken
                                                                                                                                        whilst the actual details are contained
                                                                                                                                        within the strategy meeting notes held on
                                                                                                                                        the case notes within both organisations. SERIOUS      LOW       Safety & Clinical
                                                                                                                                                                                                                               16-Jan-2009
                                                                                                                                        A copy of the form has been sent to Risk Level 15    Level 1-3    Effectiveness
                                                                                                                                        Management. The PCT feel this is now
                                                                                                                                        closed and will request closure from the
                                                                                                                                        SHA.




            As of January 2009                                                                                                                                                                                               Page 2
            North East Essex PCT                                                                    Risk Register - TOP Risks


                                                                                                                                                                                                Risk     Risk
  Date          Risk          Risk                Risk                Risk                                                                                                                                                HCC
                                                                                                Risk Description                                           Latest Update                        level    level                             Review date
 Added          Type          Area                Name               Owner                                                                                                                                             Standards
                                                                                                                                                                                              (current (Target)
22-Oct-08    Compliance   Provider &    SUI - Mortuary                JH     Certification of death.                                           LW advised that the majority of actions
                          Commissioning                                      Report due with the SHA in May 08                                 are now complete. Full completion
                                                                                                                                               expected by the end of Jan 09. The
                                                                                                                                                                                              SERIOUS       LOW       Safety & Clinical
                                                                                                                                               SHA has been updated and will closed                                                         20-Mar-2009
                                                                                                                                               when all significant actions have been         Level 15    Level 1-3    Effectiveness
                                                                                                                                               completed.

21-Jul-08    Safety       Provider &    Fire Doors and                AM     A number of key fire doors have been identified as being in        A comprehensive assessment promptly
                          Commissioning compartmentation at                  poor condition and without smoke seals or intumescent             commissioned by Estates, which has
                                        Clacton Hospital                     strips The compartmentation elements (protection from             now been completed. Clear
                                                                             smoke and fire) of these doors are fundamental to the local       recommendations have been made in
                                                                             evacuation strategy. It helps ensure that patients and staff      the assessment, requiring some
                                                                             can evacuate into particular areas and further evacuate           significant improvements, particularly            HIGH       LOW
                                                                             away from the fire through corridors which should be              regarding several key fire doors.                                           Safety           20-Mar-2009
                                                                                                                                                                                               level 12   Level 1-3
                                                                             protected by the compartmentation integrity. The doors and        Remedial work undertaken significant
                                                                             compartmentation help to also ensure a fire is contained in       work is currently out for tender
                                                                             the area of initial ignition



11-Aug-08    Assurance    Commissioning Independent Contractors –     MB     Due to existing national complexities between PCT's and           After debate IGC, Directors and Board
                                        appropriate assurance with           Independent Contractors there are significant gaps in             have accepted a degree of risk in
                                        national SABS System                 relation to the formal acknowledgement and assurance of           relation to potential "fallout" for the PCT,
                                                                             actions to SABS (Safety Alerts Broadcast System). The             in the event that an IC have not taken
                                                                             exiting PCT system in relation to SABS and IC's is of a view      appropriate actions inline with a national
                                                                             that to meet “reasonable assurance” the PCT will ensure           safety alert.
                                                                             that the relevant safety alerts are issued only to the            The PCT have assurances that the IC
                                                                             applicable IC. The PCT then expects that the IC, inline with      have been issued any particular safety
                                                                             their moral, ethical and legal responsibility to take any         alerts and the new IC Board level                HIGH        LOW          Safety &
                                                                                                                                                                                                                                            01-Apr-2009
                                                                             required actions inline with the alert. This potentially leaves   champion will pursue this area of               level 8    Level 1-3     Governance
                                                                             the PCT exposed to a level of assurance risk and potentially      assurance.
                                                                             patient safety risk, as some alerts make it clear that a
                                                                             failure to take specific actions inline with the alert can        Risk will remain of the RR and be
                                                                             potentially pose a very significant threat to the wellbeing       reviewed in April 09.
                                                                             and health of particular patients.




            As of January 2009                                                                                                                                                                                                            Page 3
         North East Essex PCT                                                                      Risk Register - Operational

                                                                                                                                                                                        Risk                 Risk
  Date                     Risk                                 Risk                                                                                                                            Risk level             HCC
         Risk Type                        Risk Name                                       Risk Description                                          Latest Update                       level                level            Review date
 Added                     Area                                Owner                                                                                                                            (current)           Standards
                                                                                                                                                                                      (initial)            (Target)
Apr-05   Operational   Provider &      Major Evacuation Plan    MC     The Trust has no major evacuation plan in place for Clacton Due to existing demands risk will be
                       Commissioning                                   Hospital and Fryatt Hospital                                readdressed in April 09
                                                                                                                                                                                      SERIOUS   MOD       LOW        Safety       01-Apr-2009


Dec-06   Operational   Provider &      Record Management       AM/LW   Record Management within the PCT has general                      No update received - However LW has
                       Commissioning                                   Inadequacies. This is a significant issue, as the PCT has         advised JH has commenced a
                                                                       not been dealing with it appropriately for many years. Since      programme to progress all existing
                                                                       the end of 2007 good progress has been made in ensuring           Community Services risk
                                                                       all Provider Services records are appropriately recorded,         DC - 30 Oct 08, Significant improvement
                                                                       archived and filed. All of MIU and Child Health has been          has occurred, but lack of staff resource
                                                                       successfully completed and work is now focussed on                prevents further improvement.
                                                                       concluding those areas with smaller numbers of records that       Consideration is being given to recruiting
                                                                       are not currently compliant. Whilst it is not possible to say     a post to progress and manage the
                                                                       how many days the work will take to complete it is estimated      records.
                                                                       that this will be concluded by the end of April.

                                                                       Provider have over 50 filing cabinets waiting to be housed in
                                                                                                                                                                                                                     Safety &
                                                                       the PCT archive and believe that the PCT wants to archive
                                                                                                                                                                                      SERIOUS   MOD       LOW        Clinical     16-Jan-2009
                                                                       all materials from the PCT at the PCC first before opening it
                                                                                                                                                                                                                  Effectiveness
                                                                       up to other areas. DC commented that it will be a full time
                                                                       role for someone to manage and regularly archive the
                                                                       archive. All managers need reminding of their responsibility
                                                                       to
                                                                        properly manage records and archive on the basis of
                                                                       the different archive dates for children (25 years), adults
                                                                       (7 years) and diaries, message books etc (2 years). In
                                                                       addition the time taken to record a log of all records
                                                                       then they reach their destruction date has been but
                                                                       should not be underestimated!




Mar-07   Operational   Provider &      Telephone and Data       LW     Telephone and Data lines cut during burglary attempt at    No update received - However LW has
                       Commissioning   Lines                    PS     other premises on industrial estate where Kennedy House is advised JH has commenced a
                                                                       located. Risk of significantly affecting the activities and the
                                                                                                                                  programme to progress all existing                                                 Clinical
                                                                                                                                                                                       HIGH     HIGH      LOW                     16-Jan-2009
                                                                       services support by KH personnel.                          Community Services risk                                                         Effectiveness
                                                                                                                                  DC - 30 Oct 08. Order placed for
                                                                                                                                  automatic call divert system, awaiting
Jul-05   Operational   Provider &      Property Maintenance     AM     Backlog of work and ongoing maintenance not performed      Jan 09 - Ongoing Project - Work
                       Commissioning                                   on PCT premises leading to financial and Health and Safety prioritised and managed through MiCAD
                                                                       risks.                                                     system reported and progress monitored
                                                                                                                                                                                       HIGH     MOD       LOW     All Standards   01-Apr-2009
                                                                                                                                  through the Estates and Capital Working
                                                                                                                                  Group

Jun-07   Operational   Provider &      Legionella Surveys       JH     Lack of Legionella survey for PCT premises                        JH advised all surveys completed and
                       Commissioning                                                                                                     order raised for works
                                                                                                                                                                                       HIGH     HIGH      LOW        Safety       16-Jan-2009




         As of January 2009                                                                                                                                                                                                   Page 4
         North East Essex PCT                                                                      Risk Register - Operational

                                                                                                                                                                                           Risk                 Risk
  Date                     Risk                                 Risk                                                                                                                               Risk level             HCC
         Risk Type                         Risk Name                                       Risk Description                                          Latest Update                         level                level            Review date
 Added                     Area                                Owner                                                                                                                               (current)           Standards
                                                                                                                                                                                         (initial)            (Target)
Feb-08   Operational   Provider &      Vulnerable Adults        FG     Lack of Protection of Vulnerable Adults Policy.                    05/01/09 FG forwarded 2 policies to the
                       Commissioning   Policy                          Raised by the Healthcare Quality Team.                            IGC in November - one for
                                                                                                                                         Commissioning and one for Provider.
                                                                                                                                         The Provider section of the Committee
                                                                                                                                         ratified that policy, subject to inclusion of
                                                                                                                                         a section related to confidentiality, as
                                                                                                                                         recommended by Sally Harrington. This
                                                                                                                                         was drafted and forwarded to Sally who           HIGH     HIGH      LOW        Safety       01-Mar-2009
                                                                                                                                         responded on 29 December with some
                                                                                                                                         relatvely minor suggestions for
                                                                                                                                         improvement, which are now being
                                                                                                                                         completed. Anticipated completion 31
                                                                                                                                         January 2009.


Apr-08   Operational   Provider &      Contractor Services      SC     Contractor Services (Carnarvon House) Compliance of                All storage on site has been subject to a
                       Commissioning   Records                         contracted Audits from 2005 onwards, internal RA's and            further Health and Safety audit no major
                                                                       audits in relation to location of clinical records resulting in   issues were raised. An assessment of
                                                                       H&S and confidently issues.                                       additional storage which can be held off
                                                                        A key specific action documented in the audits was for the       site has been carried out and some
                                                                       local management to undertake an assessment of the risks          storage has now been moved to locked
                                                                       in relation to the current storage arrangements, which has        storage at Gorse Lane and Endex
                                                                       not occurred.                                                     Archives.A full H& S audit carried out at
                                                                                                                                         Endex archives.Another has been
                                                                                                                                         requested for Gorse Lane , this has not
                                                                                                                                         yet been carried out. Currently, liaising
                                                                                                                                                                                          HIGH     HIGH      LOW        Safety       16-Jan-2009
                                                                                                                                         with procurement to review the possibility
                                                                                                                                         of market testing the current secure
                                                                                                                                         storage provisions and the potential to
                                                                                                                                         expand. There are currently no significant
                                                                                                                                         problems in this area and the records
                                                                                                                                         stored on site are those which need to be
                                                                                                                                         readily accessed.




Apr-08   Operational   Provider &      Estates Condition        AM     Estate Condition Survey                                           Ongoing Project - Work prioritised and
                       Commissioning   Survey                          highlighted a range of issues with associated risk levels. 6      managed through MiCAD system
                                                                       High Risk areas have been identified.                             reported and progress monitored through                                     Safety, Care
                                                                                                                                                                                          HIGH     MOD       LOW                     01-Mar-2009
                                                                                                                                         the Estates and Capital Working Group                                       Environment


Apr-08   Operational   Provider &      Health & Safety (Risk    RT     The PCT has not for some time supplied essential H&S              RT - Six managers course now run
                       Commissioning   Management) Training            training specifically for local managers. This will equip the
                                       for Managers.                   manager to identify and ensure they meet their and the                                                                                        Safety, Care
                                                                                                                                                                                          HIGH     MOD       LOW                     16-Jan-2009
                                                                       PCT's responsibilities for the management of Heath &                                                                                          Environment
                                                                       Safety. This being a clear safety and




         As of January 2009                                                                                                                                                                                                      Page 5
         North East Essex PCT                                                                         Risk Register - Operational

                                                                                                                                                                                       Risk                 Risk
  Date                     Risk                                   Risk                                                                                                                         Risk level             HCC
         Risk Type                         Risk Name                                         Risk Description                                          Latest Update                   level                level            Review date
 Added                     Area                                  Owner                                                                                                                         (current)           Standards
                                                                                                                                                                                     (initial)            (Target)
Apr-08   Operational   Provider &      Breakaway/deflection       LW      Community Staff face some specific hazards and are                RT CRT training under review, but will
                       Commissioning   Training for vulnerable           considered to be more at risk due to them being naturally          commence in January 09. NHS SMS
                                       staff, particular those           more vulnerable when working and travelling within the             CRT instructor courses now available,
                                       in the community                  community setting. The most significant concern relates to         the new Risk Management Advisor
                                       setting.                          their personal safety, particularly being a victim of a physical   booked onto a course in Jan 09
                                                                         attack.

                                                                         All frontline staff must already undertake Conflict Resolution
                                                                         Training, which meets the national syllabus. This syllabus is
                                                                         delivered in the form of a one-day training course in non-
                                                                         physical intervention methods including recognising warning
                                                                         signs, communication skills, cultural and diversity
                                                                         awareness and de-escalation techniques. The aim is to                                                                                   Safety, Care
                                                                         equip staff with the skills they need to identify and                                                       SERIOUS     HIGH      MOD                   20-Mar-2009
                                                                                                                                                                                                                 Environment
                                                                         de-escalate potentially violent situations. However clearly
                                                                         there may be occasions when these de-escalation skills are
                                                                         not able to prevent a personal attack.

                                                                         It is initially assessed that the training provisions should be
                                                                         assessed, potentially particular groups may also need to
                                                                         receive
                                                                         some basic breakaway/deflection training, but not
                                                                         physical intervention training.




Apr-08   Operational   Provider &      IV Therapy                 DC     Clinical Competence in IV Therapy, a significant area of           No update received - However LW has
                       Commissioning   Competence                        concern related to IV practice, several incidents in relation to   advised JH has commenced a
                                                                         use. Who is responsible/champion for ensuring that clinical        programme to progress all existing
                                                                         practice and practice competence in relation to IV is              Community Services risk
                                                                         maintained and monitored.                                          DC, 30 Oct 08 - Training has been       SERIOUS      MOD       LOW     C5b +c        16-Jan-2009
                                                                                                                                            temporary suspended, due to poor
                                                                                                                                            attendance. Plans to establish Dec 08 /
                                                                                                                                            Jan 09


May-08   Operational   Provider &      Flooring PCC &             DC     Project underway to replace large areas of flooring in             No Update supplied
                       Commissioning   Harwich                           occupied areas (including clinical) leading to a range of          DC, 30 Oct 08 - No significant risks
                                                                         potential associated risks                                         reported                                  MOD        MOD       MOD      Safety       16-Jan-2009


Jun-08   Operational   Provider &      Information                KF     The information tool kit self assessment shows the need for KF - 1/7/2009 - The latest position on the
                       Commissioning   Governance                        a challenging work programme to improve on the level of     Statement of Compliance achievement of
                                                                         achievement against national standards                      standards shows that we have 5
                                                                                                                                     standards which are still at level '0' with 2
                                                                                                                                     standards still at level '1'. Trajectories
                                                                                                                                     have been produced which show
                                                                                                                                     achievability of level 2 on all these             HIGH       HIGH
                                                                                                                                     standards by the end of March 2009.                                   LOW   Governance      20-Mar-2009
                                                                                                                                                                                     level 12   level 12
                                                                                                                                     Information Governance Steering Group
                                                                                                                                     receives and monitors deliverability of the
                                                                                                                                     objective of achieving level 2 by the end
                                                                                                                                     of March 2009.




         As of January 2009                                                                                                                                                                                                  Page 6
         North East Essex PCT                                                                      Risk Register - Operational

                                                                                                                                                                                          Risk                 Risk
  Date                     Risk                                Risk                                                                                                                               Risk level             HCC
         Risk Type                         Risk Name                                      Risk Description                                            Latest Update                       level                level            Review date
 Added                     Area                               Owner                                                                                                                               (current)           Standards
                                                                                                                                                                                        (initial)            (Target)
Jun-08   Operational   Provider &      IT Security             KF     Information Governance - IT Security                                KF - 7/1/2009 progress reports provided
                       Commissioning                                  Internal audit reports for IT security and data quality, these      to the Information Governance Steering
                                                                      highlight a number of priority level 1 and 2 items for action.      Group who is monitoring the
                                                                                                                                          achievements against the
                                                                                                                                                                                          HIGH       HIGH
                                                                                                                                          recommendations. Progress will now be                                LOW      Governance   20-Mar-2009
                                                                                                                                                                                        level 12   level 12
                                                                                                                                          further enhanced by the take up of the
                                                                                                                                          Records Manager position in January
                                                                                                                                          2009.

Jun-08   Operational   Provider &      Encryption Software     JW     Information Governance - Encryption Software                        KF - 26 Oct 2008 - encryption
                       Commissioning                                   the implementation of the encryption software / functionality      procurement for PCT PCC's complete
                                                                      across all GP sites for all equipment may not be carried in         with implementation to be made by end
                                                                      the appropriate timescales required.                                of December 2008. PCT policy still to be
                                                                      - the PCT is currently unable to setup / facilitate remote          developed in relation to remote access
                                                                      access for GP‟s until the encryption policy is determined.          so to contingency plan should ESSA fail
                                                                      Access to their clinical systems / email may adversely affect       to deliver by the end of December 2008.
                                                                      the GP‟s ability to provide appropriate patient care.                                                               HIGH       HIGH      MOD
                                                                                                                                                                                                                        Governance   20-Mar-2009
                                                                      - the on-going management of the encryption software is             KF - Dec 2008 - Finalise draft of GP          level 12   level 12   Level 6
                                                                      dependant on Essay's ability to deliver and continually             surgery survey on risk assessment on
                                                                      manage the encryption keys. The PCT currently has no                encryption risks – first draft completed on
                                                                      contingency if ESSA fail to deliver for any reason.                 audit with risk assessment to follow




Jun-08   Operational   Provider &      Issuance and Billing    JW     Information Governance - Issuance and Billing for N3             KF - 26 Oct - PCT policy still to be
                       Commissioning   for N3 Tokens                  Tokens                                                           produced.
                                                                      - billing the GP practices for the initial cost of the N3 tokens
                                                                      and the on-going monthly rental costs is not yet determined.
                                                                      The lack of process may result in financial loss for the PCT                                                       HIGH       HIGH       LOW
                                                                                                                                                                                                                        Governance   20-Mar-2009
                                                                      and poor service received by the GPs and increase in                                                              level 9    level 9    Level 1
                                                                      complaints to the IM&T dept.
                                                                      - PCT policy regarding the costs for replacements (when
                                                                      lost / damaged) is not determined.

Jul-08   Operational   Provider &      Missing Child Health    LW     Information Governance - Children's health records missing          No update supplied
                       Commissioning   Records                        in the post                                                         RT 2 Oct 08 - Issue raised with the
                                                                      Numerous incidents have occurred where requested health             Information Governance Steering Group
                                                                      records have not reached the PCT office.                            to raise direct with LW.

                                                                      • It is expected that this is directly related to the new edition
                                                                      of the Community Services Directory (covering most of the
                                                                      Country) continues to list East Lodge Court as the contact
                                                                                                                                                                                         HIGH       HIGH       LOW
                                                                      address (despite attempts from the PCT to get this                                                                                                Governance   16-Jan-2009
                                                                                                                                                                                        level 9    level 9    Level 1
                                                                      corrected)

                                                                      • The mail re-direct arrangement with the Royal Mail,
                                                                      regarding East Lodge Court expired around the new year.
                                                                      Undelivered mail apparently ends up in Belfast, where it is
                                                                      opened and returned to sender, if the sender is apparent.




         As of January 2009                                                                                                                                                                                                     Page 7
         North East Essex PCT                                                                     Risk Register - Operational

                                                                                                                                                                                      Risk                 Risk
  Date                     Risk                                Risk                                                                                                                           Risk level             HCC
         Risk Type                         Risk Name                                      Risk Description                                        Latest Update                       level                level            Review date
 Added                     Area                               Owner                                                                                                                           (current)           Standards
                                                                                                                                                                                    (initial)            (Target)
Jul-08   Operational   Provider &      Posting of Child        LW      Information Governance - Standard Child Health records      No update supplied
                       Commissioning   Health Records                 currently being sent by the PCT as standard post, 2nd class RT - 2 Oct 08 - Issue raised with the
                                                                                                                                   Information Governance Steering Group
                                                                      • Apart from child protection health records, which go       to raise direct with LW.
                                                                      recorded delivery, all other child health records are posted
                                                                      standard post, 2nd class from the PCT.                                                                         HIGH      HIGH      LOW
                                                                                                                                                                                                                  Governance   16-Jan-2009
                                                                      • Dozens of large parcels are posted every day, from                                                          level 9   level 9   Level 1
                                                                      various child health sites. Post from some sites such as
                                                                      mostly, go to Clacton Hospital for franking.



Aug-08   Operational   Provider &      Transfer of person-     KF     Information Governance                                           KF 1/1/2009 - further audit being
                       Commissioning   identifiable data by                                                                            undertaken at request of SHA on any
                                       post/courier                   The SHA have informed the PCT that “all transfers of             other personal identifiable information
                                                                      person-identifiable data by post or courier should have          which is to be completed by 16th
                                                                      ceased unless they are essential for patient care, in which      January. Plans for progressing person
                                                                      case acceptabnce of these risks should be accepted by            identifiable data transfers with GPs to be
                                                                      your Board and evidenced in your risk register"                  confirmed following the early 2008 work
                                                                                                                                       on seeking information from the
                                                                      The PCT have procedures in place which allow information         practices. In meantime, Caldicott log
                                                                      essential for patient care to be transferred via more secure     register in place with associated risk
                                                                      means. Where PCT senders are not able to comply with             assessments now part of the process -
                                                                      the procedures, a request will need to be made to the            log information presented to the
                                                                      Information Governance Team, who will ask the Caldicott          Information Governance Steering Group
                                                                      Guardian to make a discussion/approval on the request.           at each meeting.
                                                                      An example could be PCT Incident Reporting Forms, where                                                        HIGH                LOW
                                                                                                                                                                                              MOD                 Governance   20-Mar-2009
                                                                      sending by secure mail is considered realistically                                                            level 9             Level 3
                                                                      unachievable and would have a significant impact on
                                                                      incident reporting levels and thus patient safety.

                                                                      All situations of non-compliance will be assessed by the
                                                                      Caldicott Guardian and logged of a registered. However
                                                                      there will be an element of residual risk with the transfer of
                                                                      data




Oct-08   Operational   Provider &      Blood Transfusion       DC     Current trend of poor attendance at the Blood Transfusion        No update received - However LW has
                       Commissioning   Training                       yearly mandatory updates and extremely poor completion of        advised JH has commenced a
                                                                      competencies for taking a blood sample and giving a              programme to progress all existing
                                                                      transfusion we are not going to meet the required NPSA           Community Services risk
                                                                      figure of 50% compliance by May 2009                             30 Oct 08, DC - Poor attendance
                                                                                                                                       strongly linked to IV Competency Risk,
                                                                                                                                       as this must be attended before               MOD       MOD       LOW
                                                                                                                                                                                                                  Governance   16-Jan-2009
                                                                                                                                       undergoing BT Training. It is believed       level 6   level 6   Level 2
                                                                                                                                       that the issue will be successfully
                                                                                                                                       addressed, allowing achievement of the
                                                                                                                                       NPSA training requirement level.
                                                                                                                                       DC advised on initial risk level.




         As of January 2009                                                                                                                                                                                               Page 8
            North East Essex PCT                                                                  Risk Register - Operational

                                                                                                                                                                                      Risk                 Risk
  Date                        Risk                             Risk                                                                                                                           Risk level             HCC
            Risk Type                         Risk Name                                  Risk Description                                         Latest Update                       level                level            Review date
 Added                        Area                            Owner                                                                                                                           (current)           Standards
                                                                                                                                                                                    (initial)            (Target)
27-Nov-08   Information   Commissioning   GP Data Security     KF     Information Governance risk associated with GP's             Assessment of a range of risks related to
            Governance                                                Information Security systems.                                GP data security is currently underway
                                                                                                                                   and an action plan will be produced. The
                                                                      Assessment of a range of risks related to GP data security action plan will identifying what is required
                                                                      is currently underway and an action plan will be produced.   for safe systems, in terms of clinical
                                                                      The action plan will identifying what is required for safe   Services, physical IT security (lap
                                                                      systems, in terms of clinical Services, physical IT security tops,desktops and USB sticks), Domain
                                                                      (lap tops,desktops and USB sticks), Domain Controllers and Controllers and File Servers . Report
                                                                      File Servers . Report and action plan to be completed by and action plan to be completed by
                                                                      December 08                                                  December 08. 7/1/2009 - the initial report
                                                                                                                                   on the survey is to be received for the           HIGH      HIGH      LOW
                                                                                                                                   Information Governance Steering Group                                          Governance   02-Dec-2008
                                                                                                                                                                                    level 8   level 8   Level 2
                                                                                                                                   in January. Further more extensive
                                                                                                                                   assessments in place for completion by
                                                                                                                                   end of January 2009. Encryption of back
                                                                                                                                   up tapes completed for the three system
                                                                                                                                   suppliers for practices with remaining one
                                                                                                                                   to be tested re validation. Please see
                                                                                                                                   'encryption' entry above also.




3-Dec-08    Information   PCT wide        Toolkit SOC - 103    JW     IG Toolkit SOC requirement - one of 18 mandatory                No update supplied
            Governance                                                requirements which must be at min level 2 by Mar 09.            19-Dec-2008 expect to have
                                                                                                                                      components to achieve level 2
                                                                      Non achievement of the mandatory SOC requirements can           completed by end January. The new
                                                                      result in the loss of an orgnaisation's N3 connection via       person in post is confirmed to start on 5
                                                                      CFH. However, there have been no known instances                Jan and will be focussing on developing
                                                                      where CFH have disconnected an N3 connection to date.           necessary requirements.
                                                                                                                                                                                     MOD       MOD       LOW
                                                                      The PCT are at risk of not achieving the min level 2                                                                                        Governance   16-Jan-2009
                                                                                                                                                                                    level 6   level 6   Level 2
                                                                      because the appointed person to cover the role of
                                                                      "Information Security and Records Manager" is not in post
                                                                      until Jan 09. Work on the Information Security Mgt Plan
                                                                      must be commenced before January in order to handover
                                                                      and be completed by the new role from January onwards.




3-Dec-08    Information   PCT wide        Toolkit SOC - 108    JB     IG Toolkit SOC requirement - one of 18 mandatory                06-Jan-09 - Progress continues to be
            Governance                                                requirements which must be at min level 2 by Mar 09.            made across the 6 remaining SOC items
                                                                                                                                      that are not currently at level 2. Still on
                                                                      Non achievement of the mandatory SOC requirements can           target for the end of Mar for achievement
                                                                      result in the loss of an orgnaisation's N3 connection via       of level 2.
                                                                      CFH. However, there have been no known instances
                                                                      where CFH have disconnected an N3 connection to date.                                                          MOD       MOD       LOW
                                                                                                                                                                                                                  Governance   15-Dec-2008
                                                                                                                                                                                    level 5   level 5   Level 2
                                                                      The completion of this requirement is directly linked to the
                                                                      other 17 mandatory SOC requirements and cannot be
                                                                      achieved if any of the other 17 are not at level 2 by Mar 09.




            As of January 2009                                                                                                                                                                                            Page 9
           North East Essex PCT                                                            Risk Register - Operational

                                                                                                                                                                             Risk                 Risk
  Date                       Risk                        Risk                                                                                                                        Risk level             HCC
           Risk Type                    Risk Name                                  Risk Description                                      Latest Update                       level                level            Review date
 Added                       Area                       Owner                                                                                                                        (current)           Standards
                                                                                                                                                                           (initial)            (Target)
3-Dec-08   Information   PCT wide   Toolkit SOC - 113    FG     IG Toolkit SOC requirement - one of 18 mandatory              The information Governance assessment
           Governance                                           requirements which must be at min level 2 by Mar 09.          tool has been completed by 498 persons
                                                                                                                              with 203 passing. 208 people have
                                                                Non achievement of the mandatory SOC requirements can         registered but not yet taken the
                                                                result in the loss of an orgnaisation's N3 connection via     assessment with an estimated 800
                                                                CFH. However, there have been no known instances              persons across the trust still to register
                                                                where CFH have disconnected an N3 connection to date.         and/or take the test. Those still needing
                                                                                                                              to register and/or take the assessment
                                                                Assessment of staff training needs for IG and the provision   will be targeted to attend awareness
                                                                of job role specific training.                                sessions planned for March 2009 when
                                                                                                                              they will also be expected to complete
                                                                                                                                                                            MOD       MOD       LOW
                                                                                                                              the test. A meeting with QT&C has been                                     Governance   15-Dec-2008
                                                                                                                              arranged for the 29th Jan 09 to plan         level 6   level 6   Level 2
                                                                                                                              development of on-going awareness
                                                                                                                              sessions targeted at specific job
                                                                                                                              roles/and or responsibilities. This
                                                                                                                              programme will be developed by 27th
                                                                                                                              Feb 09 and presented to the next
                                                                                                                              available IG steering group for approval.




3-Dec-08   Information   PCT wide   Toolkit SOC - 206    SH     IG Toolkit SOC requirement - one of 18 mandatory              06-Jan-08. Discussions in progress with
           Governance                                           requirements which must be at min level 2 by Mar 09.          health care quality re training in-house
                                                                                                                              auditors. 2 named auditors identified
                                                                Non achievement of the mandatory SOC requirements can         from IM&T team. The development of
                                                                result in the loss of an orgnaisation's N3 connection via     documented audit procedures and audit
                                                                CFH. However, there have been no known instances              specs is progressing. Target date - end       MOD       MOD       LOW
                                                                where CFH have dicsonnected an N3 connection to date.         of Feb 09. Absolute deadline - end Mar                                     Governance   15-Dec-2008
                                                                                                                                                                           level 6   level 6   Level 2
                                                                                                                              09
                                                                To ensure the PCT has confidentiality audit procedures to
                                                                monitor access to confidential patient information



3-Dec-08   Information   PCT wide   Toolkit SOC - 208    SH     IG Toolkit SOC requirement - one of 18 mandatory              06-Jan-08. All Directorates have collated
           Governance                                           requirements which must be at min level 2 by Mar 09.          and logged their data flows into the CfH
                                                                                                                              data flow mapping tool. The main
                                                                Non achievement of the mandatory SOC requirements can         content of the safe haven policy has
                                                                result in the loss of an orgnaisation's N3 connection via     been approved by Info Gov Steering Gp.
                                                                CFH. However, there have been no known instances              Analysis of the mapped data flows is now      MOD       MOD       LOW
                                                                where CFH have dicsonnected an N3 connection to date.         required, and any risks assessed and                                       Governance   01-Mar-2009
                                                                                                                                                                           level 6   level 6   Level 2
                                                                                                                              mitigated. The policy needs a summary
                                                                Mapped flows of PID and safe havens in place.                 of flows as an appendix before
                                                                                                                              publication. Target and absolute
                                                                                                                              deadline - end of Mar 09




           As of January 2009                                                                                                                                                                                  Page 10
           North East Essex PCT                                                             Risk Register - Operational

                                                                                                                                                                               Risk                 Risk
  Date                       Risk                        Risk                                                                                                                          Risk level             HCC
           Risk Type                    Risk Name                                  Risk Description                                        Latest Update                       level                level            Review date
 Added                       Area                       Owner                                                                                                                          (current)           Standards
                                                                                                                                                                             (initial)            (Target)
3-Dec-08   Information   PCT wide   Toolkit SOC - 308    JW     IG Toolkit SOC requirement - one of 18 mandatory                19-Dec-08 Essex Charter is to be
           Governance                                           requirements which must be at min level 2 by Mar 09.            adopted as overarching legal framework
                                                                                                                                in accordance with SHA advice.
                                                                Non achievement of the mandatory SOC requirements can           Individual protocols to be prepared and
                                                                result in the loss of an orgnaisation's N3 connection via       agreed with the relevant organisations.
                                                                CFH. However, there have been no known instances                Complete list of participants data sharing    MOD       MOD       LOW
                                                                                                                                                                                                           Governance   15-Dec-2008
                                                                where CFH have dicsonnected an N3 connection to date.           partners to be completed by mid Jan.         level 6   level 6   Level 2
                                                                                                                                Protocols expected to be completed by
                                                                Ensuring that the PCT's digital information, shared with        end Feb with timetable for sign off.
                                                                other organisations, is secured in transit.


3-Dec-08   Information   PCT wide   Toolkit SOC - 401    JM     IG Toolkit SOC requirement - one of 18 mandatory                The strategy will be to use the NHS
           Governance                                           requirements which must be at min level 2 by Mar 09.            Number Programme Guidance to
                                                                                                                                develop an NHS Number Policy to
                                                                Non achievement of the mandatory SOC requirements can           reinforce the general Data Quality Policy
                                                                result in the loss of an orgnaisation's N3 connection via       in the area of managing NHS numbers.
                                                                CFH. However, there have been no known instances                This will be supported by a procedure
                                                                where CFH have dicsonnected an N3 connection to date.           that outlines the regular checks to be        MOD       MOD       LOW
                                                                                                                                                                                                           Governance   16-Jan-2009
                                                                                                                                undertaken and the resulting actions         level 6   level 6   Level 2
                                                                Ensuring the PCT have a strategy to ensure the correct          required to rectify missing NHS numbers.
                                                                NHS Number is recorded for each active patient and              This can be achieved within the
                                                                ensures that it is used routinely in clinical communications.   timescales.




           As of January 2009                                                                                                                                                                                    Page 11
         North East Essex PCT                                                                       Risk Register - SfBH


                                                                                                                                            Latest Update                                      Risk      Risk
  Date    Risk                                         Risk                                                                                                                     Risk level                            HCC
                  Risk Area           Risk Name                                  Risk Description                                                                                              level     level               Review date
 Added    Type                                        Owner                                                                                                                      (initial)                         Standards
                                                                                                                                                                                             (current) (Target)
May-07    SfBH   Commissioning SfBH Medical Devices   AM/LB   SfBH Medical Devices C4b                                         No update
                   & Provider  C4b                    /LW     In December 2006 a serious untoward incident was notified        Medical Device Officer now being
                    Services                                  to the Strategic Health Authority. This incident identified      advertised. Once post is in place, they will
                                                              areas of risks associated with the acquisition and use of        progress this work.
                                                              medical devices. The risks are now known and in
                                                                                                                                                                                 SERIOUS       HIGH      LOW      (See Column C)   16-Jan-2009
                                                              accordance with guidance issued by the MHRA, NEEPCT
                                                              have a draft policy for the „Safe use of Medical Devices‟
                                                              and will develop an implementation strategy to
                                                              operationalise the policy.

Jun-07    StBH   Commissioning SfBH Records           AM/KF   SfBH Records Management C9                                       7/1/2009 KF - Records Manager potholder
                   & Provider  Management C9          /LW     1. To perform a baseline assessment right across the PCT         now in place with progress to be made
                    Services                                  of the locality, storage, security and management (i.e.          against the NHS IG Toolkit requirements
                                                              indexing and file movement logging methods) of all paper         and audit requirements. Progress is being
                                                              records pertaining to staff and patient records. Obviously,      reported to the Information Governance
                                                              identifying what form of records these are (e.g. children's'     Steering Group.
                                                              records, CPD etc).
                                                              2. To perform a baseline assessment of the forms of
                                                              database records and systems held by staff across the
                                                              PCT. This is to identify the types of records being retained
                                                              by staff and the uses to which they are put. This will include
                                                              the retention of computerized records of staff, the public
                                                              and patients. IM&T did make a start on this at one stage.                                                          SERIOUS       LOW       LOW      (See Column C)   20-Mar-2009
                                                              3. To resurrect and apply the Information Governance
                                                              Toolkit.
                                                              4. To reassess the requirements of the relevant Healthcare
                                                              Commission Standards for Better Health with regards to
                                                              information governance and records management and
                                                              refresh the score of the PCT. This will establish what
                                                              ground we have to make up.
                                                              5. Research and write the NEEPCT Records Management
                                                              Policy.



Oct-07   SfBH    Commissioning Contracted Clinical      DC    Contracted Clinical Cleaning - Monitoring                        No update received - However LW has
                   & Provider  Cleaning                       arrangements                                                     advised JH has commenced a
                    Services                                  Standards and audit specifications are known however             programme to progress all existing
                                                              operational managers are not aware of formal standards or        Community Services risk
                                                              the Carillon contract monitoring framework which should          30 Oct 08, DC reported that he felt
                                                              meet national specification. This does not allow the PCT to      monitoring arrangement appropriate for
                                                              accurately assess compliance status or monitor the clinical      local managers are now in place. Further                                                Care
                                                              cleaning arrangements and therefore poses a clinical and         monitoring should be through a facilities         SERIOUS       HIGH      LOW       Environment     16-Jan-2009
                                                              performance risk. It is also expected that this particular       manager. LB to make comment                                                            (C21)
                                                              issue is may prevent compliance with the HCC and DH
                                                              standards and applicable legislation, namely the Health Act
                                                              2006 Code of Practice for the Prevention and Control of
                                                              Health Care Associated Infections



Dec-07   SfBH    Commissioning Isolation Facilities    JB     Lack of Isolation facilities at Clacton Hospital                 LDP has been approved to turn a side
                   & Provider                                                                                                  room on Durban and SOP into ensuite
                                                                                                                                                                                                                       Care
                    Services                                                                                                   facilities for the two rooms either side. This
                                                                                                                                                                                  HIGH         HIGH      LOW       Environment     20-Mar-2009
                                                                                                                               side room issue will be looked at in
                                                                                                                                                                                                                      (C21)
                                                                                                                               conjunction with single sex wards.




         As of January 2009                                                                                                                                                                                                 Page 12
          North East Essex PCT                                                                      Commissioning Risks Only
                                                                                                                                Latest Update
   Date      Risk                                           Risk                                                                                                            Risk level Risk level Risk level       HCC             Review
                       Risk Area      Risk Name                            Risk Description
  Added      Type                                          Owner                                                                                                             (initial) (current) (Target)       Standards           date
Dec-07    SfBH       Commissioning   18 Week Referral       MB     Failure to achieve the 18 week          Delivered VS standard week ending 16 Nov 08 and
                                     to Treatment                  "Referral To Treatment" (RRT) Target. maintained since, however, complex target with many risks -
                                                                   This could have a significant impact in eg winter pressures                                                                                   Vital Signs
                                                                   our compliance to the HCC standards                                                                       SERIOUS     HIGH        LOW         VSA04 and        19-Jan-2009
                                                                   and would have some media interest.                                                                                                             VSA05


Aug-08    SfBH       Commissioning   VS Target -            MB     Failure to achieve VS target -          New indicator associated with "Going Further on Cancer
                                     referral to                   Proportion of patients with breast      Waits". Currently constructing data collection, in conjunction
                                     specialist within 2           symptoms referred to a specialist       with CHUFT and Essex Cancer Network. We hold weekly
                                     weeks                         who are seen within two weeks of        meetings with CHUFT on cancer waits. Remains high risk
                                                                                                                                                                                                                 Vital Signs
                                                                   referral                                until there is robust information to act on and we know we are     HIGH       HIGH        LOW                          19-Jan-2009
                                                                                                                                                                                                                   VSA08
                                                                                                           delivering against trajectories. £50k allocated to CHUFT in
                                                                                                           0809 to set up systems and for MDTs not in tariff 0809.


Aug-08    SfBH       Commissioning   VS Target - 31         MB     Failure to achieve VS target -          New indicator associated with "Going Further on Cancer
                                     days for                      Proportion of patients waiting no       Waits". Currently constructing data collection, in conjunction
                                     drugs/treatment               more than 31 days for second or         with CHUFT and Essex Cancer Network. We hold weekly
                                                                   subsequent treatment (surgery &         meetings with CHUFT on cancer waits. Remains high risk                                                Vital Signs
                                                                   drugs) and related other targets        until there is robust information to act on and we know we are     HIGH       HIGH        MOD       VSA11, VSA12       19-Jan-2009
                                                                                                           delivering against trajectories. £50k allocated to CHUFT in                                          and VSA13
                                                                                                           0809 to set up systems and for MDTs not in tariff 0809.


Aug-08    SfBH       Commissioning   VS Target -            MB     Failure to achieve VS target -        £100k allocated to CHUFT in 08/09 to set up databases and
                                     Stroke Strategy               Implementation of the stroke strategy complete baseline audit and pump priming clinical activities.
                                                                                                         The peer review assessed CHUFT's state of readiness as
                                                                                                         significantly lower than CHUFT's own self assessment. The                                               Vital Signs
                                                                                                                                                                              HIGH       HIGH        LOW                          19-Jan-2009
                                                                                                         peer review concluded that substantial improvement would                                                  VSA14
                                                                                                         be required to achieve 24 hour thrombolysis status


Aug-08    SfBH       Commissioning   Primary Dental         MB     Failure to achieve VS target - Primary Commissioning plans scrutinised by national PCC dental
                                     Services                      Dental Services                        team, SHA and Essex advisors, however patients are only
                                                                                                          recorded as "new" when start treatment, so time lag from
                                                                                                                                                                                                                 Vital Signs
                                                                                                          assessment to start of treatment means unlikely to meet             HIGH       HIGH        MOD                          19-Jan-2009
                                                                                                                                                                                                                   VSB18
                                                                                                          March 09 target.


Oct-08    SfBH       Commissioning   Three month            MB     There have been ?2 breaches in          Breaches at the Essex Cardiothoracic Centre in Sept and Oct
                                     maximum wait for              CABG waiting time. One is validated     - recovery plan agreed with EoE Specialised Commissioning
                                     revascularisation                                                     team and Essex Cardiac Network. We will not meet HCC                                                 Existing target
                                                                   and confirmed, the other is under                                                                          HIGH       HIGH        MOD                          19-Jan-2009
                                                                                                           target. Reported to December Finance and Performance                                                     EC06
                                                                   query.
                                                                                                           Committee.
Aug-08    SfBH       Commissioning   Ambulance Trust        MB     Failure to achieve the existing      In year recovery plan and associated investment agreed with
                                     Response                      commitment - All ambulance trusts to EoE Ambulance Trust - position improving but best case
                                                                                                                                                                                                                Existing target
                                                                   respond to 75 percent of Category A likely to be achieving "amber" by year end.
                                                                                                                                                                              HIGH       HIGH        LOW       EC11, EC12 and 19-Jan-2009
                                                                   calls within 8 minutes and associate
                                                                                                                                                                                                                    EC13
                                                                   other targets

Jan-09    SfBH       Commissioning   Four-hour              WT     Four-hour maximum wait in A&E from      CHUFT undertaking a series of actions/reviews in order to
                                     maximum wait in               arrival to admission, transfer or       stabilise and transform the care delivered to patients eg.
                                     A&E from arrival              discharge;                              Escalation planning, roles of on call teams, annual leave
                                     to admission,                 CHUFT are below target (we are          rotas, staffing establishments in A&E, discharge processes,                                          Existing target
                                                                                                                                                                              HIGH       HIGH        MOD                          19-Jan-2009
                                     transfer or                   above overall including MIUs).          capacity planning and workforce skill mix and staffing                                                   EC01
                                     discharge;




          As of January 2009                                                                                                                                                                                              Page 14
            North East Essex PCT                                                                       Commissioning Risks Only
                                                                                                                                   Latest Update
   Date        Risk                                           Risk                                                                                                             Risk level Risk level Risk level      HCC        Review
                            Risk Area      Risk Name                           Risk Description
  Added        Type                                          Owner                                                                                                              (initial) (current) (Target)      Standards      date
Jan-09      Operational   Commissioning   Stroke Services      MB     Failure to achive pathway               >NHS North East Essex is supporting CHUFT to become a
                                                                      specfication                            24/7 acute stroke unit.
                                                                                                              >The Essex Stroke Clinical Advisory Group and Network
                                                                                                              Board have undertaken an informal peer review in December
                                                                                                              2008, prior to the accreditation review by the Royal Collage
                                                                                                              of Physicians planned for March 2009.
                                                                                                              >The peer review assessed CHUFT‟s state of readiness as
                                                                                                              significantly lower than CHUFT‟s own self assessment. The
                                                                                                              peer review concluded that substantial improvement would            HIGH       HIGH                   Various
                                                                                                                                                                                                        LOW                    19-Jan-2009
                                                                                                              be required to achieve 24 hour thrombolysis status                 level 8    level 8                Standards
                                                                                                              >Workforce and capacity were the priority areas to be
                                                                                                              resolved to enable deliver of enhanced stoke services (both 9-
                                                                                                              5 and 24/7 thrombolysis).
                                                                                                              CEOs met on 6th January to discuss and CHUFT completing
                                                                                                              action plan to deliver services in January 09



Jan-09      Operational   Commissioning   Renal Services       MB     There are capacity issues relating to   There is a North East Essex community plan in place to
                                                                      hospital dialysis services.             resolve both short and long terms issues and this is reviewed
                                                                                                                                                                                  HIGH       MOD                    Various
                                                                                                              on a monthly basis. The plan was refined from feedback at                                 LOW                    19-Jan-2009
                                                                                                                                                                                 level 8    level 6                Standards
                                                                                                              the Renal Open Day in September 2008.

28-Oct-08   Compliance    Commissioning   Lack of            Jhanvey In 2006/7 The Audit Commission             A subsequent audit has now been completed and an update
                                          legal compliance           (Essex) undertook a Charitable Funds       requested from the audit commission on their views.
                                          in relation to             Annual Governance Audit. The report
                                          charitable funds           highlighted a number of areas where the
                                                                                                                                                                                  HIGH       HIGH       LOW
                                          and relevant               PCT are failing to meet its statute duties                                                                                                   Governance   04-Nov-2008
                                                                                                                                                                                 level 8    level 8   Level 1-3
                                          financial                  in relation to charitable funds and
                                          arrangements               relevant financial arrangements.




            As of January 2009                                                                                                                                                                                            Page 15
           North East Essex PCT                                                                                       Assurance Framework

  ID     Date     Risk       Risk Area          Stategic Objective           Risk Principal Risk Description                Key Controls                 Action       Target date           Latest Update   Risk level   Risk level   Risk level   Review date
        Added     Type                                                      Owner                                                                        Owner                                               (initial)   (current)     (Target)
SO1.1   Nov-08 Assurance   Commissioning - Strategic Objective (SO1) -     MG &   Annualising of deliverables     1. Review currency and              DOM             1. Achieved Oct 08                                                           Closed
                           Assurance       Annualise the deliverables to   MB     could be affected by            effectiveness of present HNA.
                           Framework       achive the 5 Year Health               potential deficiencies in
                                           Strategy's commitments and             some areas of the Health        2. Debate prioritisation of work-                   2. Achieved Oct 08
                                           design process for strategy            Needs Assessment (HNA).         plan at Weekly Directors Meeting.
                                           rewiew and accommondation of           Negated Oct 08                                                                                                              HIGH         LOW          LOW
                                           evloving national and other
                                           service/policy developments for
                                           e.g outcomes of Darzi Review


SO1.2                                                                    MG &     Early indications of public &   Identify risks associated to                        1. Achieved Sept 08                                                          Closed
                                                                         MB       patient consultations not       contrary consultation outcomes:
                                                                                  supportive of some elements     • Enhance comms plans with
                                                                                  of the PCT‟s Strategy.          media, MPs & pressure groups to
                                                                                  Negated - Sept 08               ensure evidence based proposals.
                                                                                                                  • Progress LIFT & APMS
                                                                                                                  programmes allowing for full                                                                HIGH         LOW          LOW
                                                                                                                  awareness of public views.
                                                                                                                  • Arrange equitable access to new
                                                                                                                  primary care facilities (Darzi).




SO1.3                                                                    MG &     2008/9 and subsequent       Assess Operational Plans to             AD Business     1. 30 Oct 08
                                                                         MB       Operational Plans do not    determine practical robustness to       Planning
                                                                                  have the enabling sub-plans support commitment & Strategy.
                                                                                  in place to support overall
                                                                                  commitment and Strategy                                                                                                     HIGH         LOW          LOW




SO2.1   Nov-08 Assurance   Commissioning - STRATEGIC OBJECTIVE           MB       PBC Group Plans do not          1. Continue senior PCT              AD of Primary   1. Ongoing
                           Assurance       (SO2): Develop a rolling               complement PCT‟s 5 Year         management oresence at PBC          Care & Mental
                           Framework       programme of commissioning             Strategy and PCT                Group Meetings                      Health
                                           intentions which are informed          Commitments.
                                           by the priorities from the                                             2. To identify and negotiate                        2. Achieved Sept 08
                                           Practice Based Commissioning                                           mitigation of non-complementary
                                           Groups to deliver the 5 Year                                           areas of PBC plans
                                           Health Strategy and which                                                                                 Director of                                              HIGH         LOW          LOW
                                           inform provider development                                            3. Strong liaision with PBC groups Finance &        3. 30 Nov 08
                                           and contestability activity.                                           to ensure additional plans for use Performance
                                                                                                                  of FUR meet governance
                                                                                                                  requirements and are in line with
                                                                                                                  PCT Strategy


SO2.2                                                                    MB       Change in relationship with     1. Continue to develop & enhance Director of   1. Ongoing
                                                                                  key service providers (i.e.     contractual mechanisms           Commissioning
                                                                                  ALTO & Colchester FT)
                                                                                  could detrimentally impact      2. Regularly review procurement                                                             HIGH         HIGH         LOW
                                                                                  on service commissioning &      strategy                                            2. Ongoing
                                                                                  future development plans.




           As of January 2009                                                                                                                                                                                                            Page 16
           North East Essex PCT                                                                                             Assurance Framework

  ID     Date     Risk        Risk Area           Stategic Objective            Risk Principal Risk Description           Key Controls                             Action    Target date           Latest Update   Risk level   Risk level   Risk level   Review date
        Added     Type                                                         Owner                                                                               Owner                                            (initial)   (current)     (Target)
SO2.3                                                                         MB     Failure to adequately      1. Ensure full engagement of key              Dir of CD&G    1. Ongoing
                                                                                     engage public & partner    stakeholders.
                                                                                     organisations in order to
                                                                                     develop Plans              2. Development of PPI Panel &                                2. Achieved Sept 08
                                                                                                                early engagement of LINKS.

                                                                                                                       3. Enhancement of Patient                             3. Achieved July 08
                                                                                                                       Commissioning Forums & review
                                                                                                                       memberships.                                                                                  HIGH         LOW          LOW
                                                                                                                       (E.g. Parish councillors now attend)


                                                                                                                       4. Explore how to become a World                      4. 31 March 09
                                                                                                                       Class Commissioner in public &
                                                                                                                       patient involvement workshops
                                                                                                                       and special events.



SO3.1   Nov-08 Assurance   Commissioning - STRATEGIC OBJECTIVE                AM       Operating Plan endangered (Managed under SO4.1)
                           Assurance       (SO3) Implement the 2008/9                  by overspend, principally
                           Framework       Operating Plan.                             influenced by unforeseen
                                                                                       expenditure and/or
                                                                                       variances to existing plans
                                                                                       including unpredicted
                                                                                       government or regional
                                                                                       initiatives


SO3.2                                                                         AM       StHA does not agree the     1. Continuing positive co-                 Dir of CD&G    1. Ongoing
                                                                                       Plan or request problematic operation & communication with
                                                                                       changes.                    SHA.

                                                                                                                       2. Continue to implement contents                     2. Ongoing
                                                                                                                       of the Plan until otherwise advised                                                           HIGH         HIGH         LOW

                                                                                                                       3. Complete refreshment of
                                                                                                                       Pledges                                               3. 30 Nov 08


SO3.3                                                                         AM       Inability to fulfil some        Regular performance reports and        Dir of CD&G    1. Ongoing
                                                                                       elements of performance         appropriate corrective action                                                                 HIGH         HIGH         LOW
                                                                                       within the Plan.                plans.
SO3.4                                                                         AM       Not achieving the delivery of   1. Effective monitoring of             AD of Business 1. Ongoing
                                                                                       the IM&T Plan and               implementation of the IM&T Plan.       Planning
                                                                                       Workforce and Estates           (Refreshed IM&T Plan sent to
                                                                                       Strategies.                     SHA end of Sept 08)
                                                                                       (See also SO7)                                                         Head of
                                                                                                                       2. Effective monitoring of             Faciliites &   2. Ongoing
                                                                                                                       implementation of the Estates          Estates
                                                                                                                                                                                                                     HIGH         HIGH         LOW
                                                                                                                       Strategy.
                                                                                                                                                              Head of HR
                                                                                                                       3. Production of workforce                            3. 31 March 09
                                                                                                                       strategy. (Draft OD Plan
                                                                                                                       progressing)


SO4.1   Nov-08 Assurance   Commissioning - STRATEGIC OBJECTIVE                CR       Unforeseen variances to         1. Effective forecasting of service    Director of    1. Ongoing
                           Assurance       (SO4): Achieve the financial                existing plans including        and expenditure needs to be            Finance &
                           Framework       control total for 2008/9 with an            unpredicted government or       captured and managed.                  Performance
                                           underpinning financial                      regional initiatives which
                                           management plan for                         could exacerbate                2. Maintaining appropriate levels                     2. Ongoing
                                           sustainable health care where               underspend position.            of contingency funding.                                                                       HIGH         HIGH         LOW
                                           all Directorates have
                                           responsibilities to achieve
                                           efficiency, effectiveness and
                                           value for money.




           As of January 2009                                                                                                                                                                                                                   Page 17
           North East Essex PCT                                                                                           Assurance Framework

  ID     Date     Risk       Risk Area            Stategic Objective           Risk Principal Risk Description                Key Controls                     Action      Target date           Latest Update   Risk level   Risk level   Risk level   Review date
        Added     Type                                                        Owner                                                                            Owner                                              (initial)   (current)     (Target)
SO4.2                                                                        CR     Surplus against control total 1. (for 2.1) – Effective forecasting
                                                                                    due to:                       of service & expenditure needs
                                                                                                                  enhanced by detailed monitoring
                                                                                    2.1 Slippage against budget of investments.                            AD of Finance   1. Ongoing
                                                                                    & investments.
                                                                                                                  2. (for 2.2) – Produce detailed
                                                                                    2.2 Inadequate use of         plans & control mechanisms to            AD of Finance   2. Ongoing
                                                                                    contingency funds.            utilise contingency.

                                                                                                                  3. (for 2.3) – Assisting the PBC
                                                                                      2.3 PBC; freed up resources Group to utilise resources in an         AD of Primary   3. Ongoing
                                                                                      not fully utilised.         appropriate and timely way.              Care & Mental
                                                                                                                                                           Health                                                SERIOUS        HIGH         LOW
                                                                                                                     4. (for 2.4) – Perform analysis of
                                                                                      2.4 Prescribing – nationally   precise scale and implications of     AD of           4. 21 Nov 08
                                                                                      agreed drug price              national drug price changes.          Medicines
                                                                                      fluctuations increase                                                Management
                                                                                      underspend position.           5. Recruitment of additional
                                                                                                                     Finance resource to assist Budget
                                                                                                                     Managers to effectively deliver   Director of         14 Nov 08
                                                                                                                     departmental financial plans.     Finance &
                                                                                                                                                       Performance




SO5.1   Nov-08 Assurance   Commissioning - STRATEGIC OBJECTIVE              CR &      Outcome of external            Commissioning service                                 1. Achieved June 08
                           Assurance       (SO5): Design, implement and MB            Framework for External         improvement plan to be
                           Framework       resource effective                         Support of Commissioning       developed, subsuming the
                                           commissioning, contracting and             (FESC) review identifies       Capacity & Capability
                                           procurement functions each of              gaps in commissioning &        Development Plan.
                                           which are clearly defined within           procurement processes.                                                                                                       HIGH         LOW          LOW
                                           an overarching framework and               (Note: Review concludes in
                                           each with the appropriate                  Aug 08).
                                           skilled capacity to deliver.               Negated – Sept 08
                                                                                      (4 separate workstreams
                                                                                      developed)

SO5.2                                                                        CR &     Delay in recruiting to and     Inventive recruitment methods to      Director of     31-Jan-09
                                                                             MB       thereby activating             be employed.                          Finance &
                                                                                      Contracting Unit                                                     Performance
                                                                                      constraining ability to                                                                                                      HIGH         HIGH         LOW
                                                                                      implement plans and
                                                                                      contracting commitments.
SO5.3                                                                        CR &     Inability to recruit relevant  Identify specialist skill providers   Director of     30-Nov-08
                                                                             MB       resource with pertinent skills (e.g. agencies) to fill missing       Finance &
                                                                                      and project management         resources.                            Performance
                                                                                      experience to enable in-year                                                                                                 HIGH         HIGH         LOW
                                                                                      plans to be delivered.


SO6     Nov-08 Assurance   Commissioning - STRATEGIC OBJECTIVE               PZR &    Lack of approval of            1. Continue close co-operation                        1. Achieved Sept 08
                           Assurance       (SO6): Develop and achieve a      AM       recommended benefits           with the StHA to benefit from their
                           Framework       clearly articulated benefits               realisation strategy.          expertise.
                                           realization strategy to ensure             Negated – Oct 08
                                           that the technological                                                  2. Ensuring prioritisation of input                     2. Achieved Sept 08                     HIGH         LOW          LOW
                                           advantages of Connecting for               (Realisation strategy agreed to achieve strategy.
                                           Health are realized by patients            and despatched to SHA as
                                           and providers of services.                 part gf IM&T Strategy in
                                                                                      Sept 08

SO7.1   Nov-08 Assurance   Commissioning - STRATEGIC OBJECTIVE               MB &     Progression of LIFT            1. Full details of condition survey                   1. Achieved June 08
                           Assurance       (SO7): Develop and then           AM       programme deferred due         to be entered onto MICAD.
                           Framework       implement first phase of                   delayed access to results of
                                           Estate‟s Strategy with                     estates condition survey.      2. LIFT Team to receive training to
                                           consideration of Local                     Negated – Sept 08              access MICAD data                                                                             HIGH         LOW          LOW
                                                                                                                                                                           2. Achieved Sept 08
                                           Improvement Finance Trust as
                                           one vehicle to deliver fit for
                                           purpose premises.




           As of January 2009                                                                                                                                                                                                                 Page 18
           North East Essex PCT                                                                                           Assurance Framework

  ID     Date     Risk       Risk Area            Stategic Objective           Risk  Principal Risk Description              Key Controls                Action            Target date           Latest Update   Risk level   Risk level   Risk level   Review date
        Added     Type                                                        Owner                                                                      Owner                                                    (initial)   (current)     (Target)
SO7.2                                                                        MB &   Failure to obtain land &      1. Build relationships with key    AD of LIFT            1. Ongoing
                                                                             AM     planning consent on sites     stakeholders & gain public support
                                                                                    identified for LIFT Tranche 2 for schemes.
                                                                                    schemes.
                                                                                                                  2. Establish adequate contingency                        2. 31 Mar 09                            HIGH         HIGH         LOW
                                                                                                                  funds to cope with price changes
                                                                                                                  & enable purchase of required
                                                                                                                  land
SO7.3                                                                        MB &     Deficiencies in or delay of     1. Identify key enabling strategies                  1. Achieved Aug 08
                                                                             AM       PCT strategies and plans on     and plans.
                                                                                      which Estates Strategy
                                                                                      depends could affect            2. Discuss potential problems with                   2. Achieved Sept 08                     HIGH         LOW          LOW
                                                                                      implementation of the latter.   catalytic plans, including the HNA,
                                                                                      Negated – Sept 08               with owners


SO7.4                                                                        MB &     The potential effect of the     1. Ensure early, open and honest      Director of   1. Ongoing
                                                                             AM       Provider-Commissioning          discussion and flexibility in         Commissioning
                                                                                      split which could affect        negotiations.
                                                                                      Provider acceptance of
                                                                                      ownership and occupation of     2. Ensure premise arrangements                       2. Ongoing
                                                                                      some premises.                  for the provision of services are
                                                                                      (Agreement reached that         clearly specified in commissioning
                                                                                      there will be no transfer of    contracts.                                                                                   HIGH         HIGH         LOW
                                                                                      property ownership when
                                                                                      full separation occurs.
                                                                                      Budgets for properties now
                                                                                      lie with Commissioning PCT)



SO7.5                                                                        MB &      Lack of Estates Team           Continuance of staff recruitment      Head of Estates 28-Feb-09
                                                                             AM       resource could endanger         campaign
                                                                                      furtherance of some
                                                                                      elements of the Estates
                                                                                      Strategy. (Use of agency                                                                                                     HIGH         HIGH         LOW
                                                                                      staff and short term
                                                                                      contracts temporarily
                                                                                      negated this risk)
SO8.1   Nov-08 Assurance   Commissioning - STRATEGIC OBJECTIVE               LP & AM Insufficient capacity in some 1. Continuous checking of input          Director of    1. Ongoing
                           Assurance       (SO8): Support the Arm‟s                  Corporate Service areas to required.                                   CD&G
                           Framework       Length Trading Organisation               provide required level of
                                           including the support services            support at the time required. 2. Prioritisation with Corporate                        2. 31 Oct 08
                                           division to enable the Provider                                         Services to meet identified need
                                           Arm to successfully function
                                           under this new arrangement                                                 3. Assessment of additional                          3. 31 Oct 08
                                           and prepare for their chosen                                               capacity requirements.
                                                                                                                                                                                                                   HIGH         HIGH         LOW
                                           organizational model.
                                                                                                                      4. Present sound case to PCT                         4. 21 Nov 08
                                                                                                                      Board in Nov 08 to ensure
                                                                                                                      proposed Commissioning PCT &
                                                                                                                      Provider Services structure &
                                                                                                                      resources are agreed.


SO8.2                                                                        LP & AM Lack of clarity of governance Clear proposals from Provider            Director of    21-Nov-08
                                                                                     responsibilities &            Services to be discussed and             Provider
                                                                                     arrangements could lead to agreed at Board level                       Services
                                                                                     delays in ALTO separation                                                                                                     HIGH         HIGH         LOW
                                                                                     development.




           As of January 2009                                                                                                                                                                                                                 Page 19
            North East Essex PCT                                                                                         Assurance Framework

  ID      Date     Risk       Risk Area           Stategic Objective          Risk   Principal Risk Description                 Key Controls                    Action      Target date       Latest Update   Risk level   Risk level   Risk level   Review date
         Added     Type                                                      Owner                                                                              Owner                                          (initial)   (current)     (Target)
SO8.3                                                                       LP & AM Unanticipated significant        1. Close 2-way communication           Director of     1. Ongoing
                                                                                    changes to Provider              between Provider Services on           Provider
                                                                                    Services development plans       anticipated changes, as relayed        Services
                                                                                    or challenging demands           by Provider.
                                                                                    endanger Commissioning                                                                                                      HIGH         HIGH         LOW
                                                                                    PCT‟s ability to positively      2. Realistic resolution of meeting                     2. Ongoing
                                                                                    respond within timeframe.        of requirements, led by Provider
                                                                                                                     services.
SO9.1    Nov-08 Assurance   Commissioning - STRATEGIC OBJECTIVE              PZR &   Delay in appointing to senior   Commitment to adhere to the                            Achieved Oct 07
                            Assurance       (SO9): Develop leadership and AM         and other key posts in the      consultation and recruitment
                            Framework       organizational capacity and              new Training & Development      timetable.
                                            capability through:-                     structure jeopardises           (Final appointee in post on 1st
                                            - Board Development                      progression of training         Dec 08)
                                            - identifying and utilizing              programmes.
                                            available talent and providing           Negated – Oct 08
                                            personalized support to staff to
                                                                                                                                                                                                                HIGH         LOW          LOW
                                            equip them to deliver the PCTs‟
                                            objectives
                                            - working with external
                                            providers and partners to
                                            develop and maximize overall
                                            capacity and skills available.


SO9.2                                                                       PZR &    Insufficient time commitment    1. Board to commit to increased        Chairman        1. Ongoing
                                                                            AM       from or availability of Board   time allocations to essential
                                                                                     members to training             training
                                                                                     sessions to allow
                                                                                     satisfactory development        2. Review of training programmes Director of           2. Ongoing
                                                                                     (example subjects: Equality     to ensure proposed sessions are CD&G
                                                                                     & Diversity and Risk            compact and relevant to the Board
                                                                                                                                                                                                                HIGH         HIGH         LOW
                                                                                     Management).
                                                                                     (Risk Management training       3. Equality & Diversity Training
                                                                                     organised. E & D training to    for the Board to be implemented in Head of             3. 28 Feb 09
                                                                                     be progressed)                  1st Qtr of 2009                    Training &
                                                                                                                                                        Education/ AD
                                                                                                                                                        of HR

SO9.3                                                                       PZR &    Re-launch and                   1. Finalisation of training policies   AD Specialist   1. 31 Dec 08
                                                                            AM       implementation of KSF falls     to support implementation              Services
                                                                                     behind schedule due to
                                                                                     delay in releasing staff for    2. Finalise and commence                               2. 1 Dec 08
                                                                                     system administration and       implementation of action for KSF
                                                                                     appraisal training, mainly      progression and allocate
                                                                                     because of operational          resources
                                                                                     pressures and resource
                                                                                                                                                                                                                HIGH         HIGH         LOW
                                                                                     shortages.                      3. Raising awareness of KSF and                        3. Ongoing
                                                                                                                     linked personal and business
                                                                                                                     objectives to secure staff
                                                                                                                     engagement.
                                                                                                                     (Awareness raising initiative
                                                                                                                     underway with early success)


SO10.1   Nov-08 Assurance   Commissioning - STRATEGIC OBJECTIVE               AM     Lack of consistent              1. Commitment to confirmed             Director CG&G Achieved Sept 08
                            Assurance       (SO10): Implement a robust,              agreement with F & P            performance information for
                            Framework       streamlined Performance                  Committee about what            2008/9.
                                            Management Framework that                needs to be reported.
                                            enables the Board to know the            Negated – Sept 08
                                            PCT‟s progress on all targets, to        (Needs clarified and new
                                            ensure that corrective action is         reporting format and data                                                                                                  HIGH         LOW          LOW
                                            taken to mitigate against risk of        fufills)
                                            non achievement and to
                                            become a top PCT performer in
                                            the East of England.




            As of January 2009                                                                                                                                                                                                             Page 20
            North East Essex PCT                                                                        Assurance Framework

  ID      Date   Risk      Risk Area   Stategic Objective     Risk  Principal Risk Description                Key Controls               Action    Target date       Latest Update   Risk level   Risk level   Risk level   Review date
         Added   Type                                        Owner                                                                       Owner                                        (initial)   (current)     (Target)
SO10.2                                                      AM     Delay in achieving the full      1. Commit to achieve rollout     AD Business   1. 31 Dec 08
                                                                   potential of Performance         timetable of Per. Accelerator    Planning
                                                                   Accelerator (PA).
                                                                   (Certain elements of PA as       2. Timely feedback to PA supplier AD Busines   2.Ongoing
                                                                   presented not as developed       company on any software defects. Planning
                                                                   as expected and hence                                                                                               HIGH         HIGH         LOW
                                                                   delays in progression as         3. Concentrate efforts on Risk
                                                                   PCT acts in that                 Register and Assurance           Head of       3. 31 Dec 08
                                                                   developmental role)              Framework elements of PA         Corporate
                                                                                                                                     Services

SO10.3                                                      AM      Additional targets introduced    Additional targets introduced   Ensure system Achieved Aug 08
                                                                    which challenges capacity to    which challenges capacity to     flexibility to
                                                                    performance manage.             performance manage.              respond to
                                                                    Negated – Aug 08                Negated – Aug 08                 changing
                                                                    (Performance management         (Performance management          needs.
                                                                    system sufficiently robust to   system sufficiently robust to                                                      HIGH         LOW          LOW
                                                                    respond to changing             respond to changing demands)
                                                                    demands)




            As of January 2009                                                                                                                                                                                    Page 21
              North East Essex PCT                                                                              Risk Register - Closed
                                                                                                                                                                                                Risk      Risk     Risk
       Date          Risk                                                 Risk                                                                                                                                                  HCC
ID                              Risk Area          Risk Name                                        Risk Description                                         Latest Update                      level     level    level                       Review date
      Added          Type                                                Owner                                                                                                                                               Standards
                                                                                                                                                                                              (initial) (current (Target)
65   Apr-08      Operational   Provider &    Payroll                      JK     Significant ongoing concerns with Payroll Services and the       JK Oct 08 - Weekly meetings take place
                               Commissioning                                     effect on staff.                                                 between HR and the Payroll Services
                                                                                                                                                  Manager and concerns or errors can be
                                                                                                                                                  identified at an early stage. HR continue
                                                                                                                                                  to seek improvements in payroll
                                                                                                                                                  processes and are confident that the         HIGH     LOW       LOW             n/a           07-Nov-2008
                                                                                                                                                  increased monitoring is minimising the
                                                                                                                                                  risk of any future errors. Request Risk
                                                                                                                                                  reduced to low


                 Operational   Commissioning Failure to achieve the 18    MB     Failure to achieve the 18 week supporting measures
                                             week supporting                     This could have a significant impact in our compliance to the
                                             measures                            HCC standards and would have some media interest.


                                                                                                                                                                                               HIGH     LOW       LOW       Vital Sign VSA05    19-Jan-2009




60   Apr-08      Operational   Provider &    Safeguarding Children        WT     Due to existing capacity pressures relating to Safeguarding Risk did not realise - closed by WT
                               Commissioning Consultant                          Children, Essex SCAB currently has a backlog of 7 serious
                                                                                 case reviews. This is potentially a significant child safety
                                                                                 issue as well as having an adverse impact of the PCT's
                                                                                 obligations under the "Working together to safeguard
                                                                                 Children" By July 08 one of the two Safeguarding Children
                                                                                                                                                                                              SERIOUS   MOD       LOW            Safety         07-Nov-2008
                                                                                 Consultants will be leaving the PCT and failure to recruit to
                                                                                 this post by July 08 will result in failing to meet these
                                                                                 obligations, directly impacting on children safety and welfare.
                                                                                 This outcome will be considered an Extreme risk to the PCT.



68   Jun-08      Operational   Provider &    CRB LD Service               FG     The PCT is undertaking retrospect CRB checks for all             30 Oct 08, FG - HR have clearly
                               Commissioning                                     existing staff, who due to their length in employment would      highlighted the persons requiring CRB
                                                                                 not have automatically required them to have a CRB               and have activity been undertaking. 2 In-
                                                                                 undertaken when they were employed. This is a proactive          patients and 11 Community remain
                                                                                 measure, however there is a risk that individual CRB findings    outstanding. JK and FG have report all
                                                                                 may highlight adverse information which could seriously          CRBs now completed.
                                                                                 affect or prevent continued PCT employment, or affect the
                                                                                 current role which they are undertaking. If this situation did
                                                                                 arise, clearly the primary concern is of patient and staff
                                                                                 safety & security. This aspect will significantly impact on
                                                                                                                                                                                               MOD      MOD       LOW            Safety         07-Nov-2008
                                                                                 any decision making process in relation to the ongoing
                                                                                 employment status, role or location of an individual. In the
                                                                                 event of an individual(s) are subject to significant change or
                                                                                 termination to their employment due to this process, the
                                                                                 individual may feel they have grounds to instigate a
                                                                                 grievance or seek independent legal advice




     Aug-08      SfBH          Commissioning New Health Centre           MB      Failure to achieve the "New Health Centre" target             Current procurement timetable meets the
                                             target                              This could have a significant impact in our compliance to the requirements of the DH. Proposed start
                                                                                 HCC standards and would have some media interest.             date has been changed to 1st June 2009
                                                                                                                                               in view of the PCTs board decision to                                           Vital Signs
                                                                                                                                               incorporate the services of the walk in         MOD      MOD       LOW                           7 & 17 Nov 08
                                                                                                                                                                                                                                 VSA07
                                                                                                                                               centre in with the service specification for
                                                                                                                                               the health centre.




              As of January 2009                                                                                                                                                                                                             Page22
              North East Essex PCT                                                                       Risk Register - Closed
                                                                                                                                                                                   Risk      Risk     Risk
       Date         Risk                                             Risk                                                                                                                                          HCC
ID                            Risk Area          Risk Name                                    Risk Description                                   Latest Update                     level     level    level                         Review date
      Added         Type                                            Owner                                                                                                                                       Standards
                                                                                                                                                                                 (initial) (current (Target)
     Aug-08      SfBH        Commissioning VS Target - Drug Users   MB      Failure to achieve VS target - Number of drug users       Clarification requird from NDTMS as
                                           in treatment                     recorded as being in effective treatment                  methodology for data collection has
                                                                                                                                      changed. Targets as predicted for
                                                                                                                                      problomatic drug users (PDU), (Crack &
                                                                                                                                      Heroin) 1468 for 07/08 anticipated
                                                                                                                                      3%increase for 08/09 target 1512.
                                                                                                                                      NDTMS website currently stating that we                                    Vital Signs
                                                                                                                                                                                  MOD      MOD       LOW                             7 & 17 Nov 08
                                                                                                                                      PDU are 1548 hence clarification                                             VSB14
                                                                                                                                      required. All drug use 18 + same
                                                                                                                                      concerns as target 07/08 2294 with 2%
                                                                                                                                      increase for 08/09 webiste states 2423
                                                                                                                                      which again requries clarification.


     Aug-08      SfBH        Commissioning Emergency Bed Days       MB      Failure to achieve VS target - Emergency bed days (also Identification of case managers are rising
                                                                            proxy for LTC for first year)                           , we have met the criteria for community
                                                                                                                                    matrons and another is in the recruitment
                                                                                                                                    process for ALTO providers.This raises
                                                                                                                                    profile of commissioners being actively
                                                                                                                                    able to measure the identification of
                                                                                                                                    VHIU and request targets from
                                                                                                                                                                                                                 Vital Signs
                                                                                                                                    providrs.Still difficulties beyween PARR      MOD      MOD       LOW                             7 & 17 Nov 08
                                                                                                                                                                                                                   VSC20
                                                                                                                                    system and SUS from CHUFT. Expert
                                                                                                                                    Patient Programmes commissioned for
                                                                                                                                    Q3 and Q4 of 0809 whcih will help deliver
                                                                                                                                    the target




     Aug-08      SfBH        Commissioning Achieving Independence   MB      Failure to achieve the "Achieving independence through Also Telehealth project driving forward
                                           through Rehabilitation           rehabilitation"                                        through ALTO and PBC. Evaluation to
                                                                                                                                   take place ,decision to be made whether
                                                                                                                                   to persue and way forward to be found for
                                                                                                                                   resources Also BERTIE being
                                                                                                                                   implemented for Type one diabetes to
                                                                                                                                   enable people to adjust balance between
                                                                                                                                   intake and Insulin. The objectives are to                                     Vital Signs
                                                                                                                                                                                  HIGH     HIGH      LOW                             7 & 17 Nov 08
                                                                                                                                   do 64 people per year - this requires EPP                                       VSC04
                                                                                                                                   initiative in year - Expert Patient
                                                                                                                                   Programmes commissioned for Q3 and
                                                                                                                                   Q4 of 0809 whcih will help deliver the
                                                                                                                                   target




     Aug-08      SfBH        Commissioning Diabetes Screening       MB      Failure to achieve the existing commitment - 100          Assurances give that 100% deliver being
                                                                            percent of people with diabetes to be offered screening   achieved however no formal information
                                                                            for the early detection (and treatment if needed) of      submissions being received from ALTO.
                                                                            diabetic retinopathy                                      Redesign project to be initiated
                                                                                                                                                                                                                Existing target
                                                                                                                                                                                  MOD      MOD       LOW                             7 & 17 Nov 08
                                                                                                                                                                                                                    EC17




     Aug-08      SfBH        Commissioning Psychosis Intervention   MB      Failure to achieve the existing commitment - Deliver      • Information requested from lead
                                                                            7,500 new cases of psychosis served by early              commissioners as activity available does
                                                                            intervention teams per year and associated MH targets     not provide baseline and plan or years
                                                                                                                                      08/09 09/10 & 10/11                                                       Existing target
                                                                                                                                      Information schedule in the process of      MOD      MOD       LOW       EC18, EC19 and        7 & 17 Nov 08
                                                                                                                                      being update it is anticipated that                                           EC20
                                                                                                                                      inforamtion will be available in qtr 2.




              As of January 2009                                                                                                                                                                                                  Page23

				
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