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									Appendix 1                                                                                                                                                                                                                                      Board Assurance Framework
PRINCIPAL
OBJECTIVES         S4BH                       PRINCIPAL RISKS                                              KEY CONTROLS                                          ASSURANCES ON CONTROLS                                                        GAPS
                                                                               Lead Director




                                                               residual risk
                    Healthcare
                                                                                      +
                                                                                                                                                                                                                                                  gaps in assurance ie




                    Standard
                                                                               Classification
   Operational                   CRR                                                                                                                                         positive assurances received in last 18                             negative / limited or no




                                                              score
                                                                                of principal
   Objectives                    Ref     Principal Risks                            risk                       Controls                 potential sources of assurance                   months (date)                       gaps in control        assurance (date)

CO1 To achieve Foundation Trust status by April 2008 including recurrent financial balance and sound governance arrangements

                                                                                                 Turnaround projects and plans. Annual
                                                                                                   Budget Setting + Performance Plan
                                                                                                                                                                           IA reports 04.2005/06 (Aug 05) & 18.2005/06                             Annual Audit Letter IA
                                                                                                    Cost Improvement Plan Finance
                                                                                                                                                                                                                                               report 26.2004/05 states that
                                                                                                Committee meet monthly to monitor and                                       (Feb 06) provide substantial assurance re
Achievement of the                                                                                                                                                                                                                                little progress has been
                                                                                                    review financial performance and    External audit review of annual Income Systems & debtors; IA reports 03.2005/06
Financial Recovery                                                                                                                                                                                                                             made in respect of budgetary
                                                                                                  savings strategies Detailed monthly    accounts Management Letter         & 19.2005/06 (Aug 05) provide substantial
Plan within a robust                                                                                                                                                                                                                             control (June 2005) Public
                                 178                                                               Finance reports to the Trust Board   ALE (Auditors Local Evaluation) assurance re general ledger; Strategic Service
    performance                        Failure to achieve                                                                                                                                                                                          Interest Report (July 05)
                                 177                                               FD           External scrutiny from SHA via monthly    Internal Audit Plan provides   Review diagnostic (Nov 05) identified significant
   management        C7d               recurrent financial      25                                                                                                                                                                                    highlighted serious
                                 140                                            Financial          FMR return Weekly meetings with      ongoing assurance on controls         underfunding in acute sector IA report
framework to bring                          balance                                                                                                                                                                                                concerns Taylor Sellers
                                 222                                                              budget holders Budgetary controls      relating to financial systems,  31.2005/06 on budgetary control (Jun 06) shows
   the Trust into                                                                                                                                                                                                                                 review (Sept 05) Nov 06:
                                                                                                       Delegated expenditure limits        reconciliation processes +            reasonable implementation of
 recurrent financial                                                                                                                                                                                                                            Issue regarding accounting
                                                                                                Shropshire Programme Board Reduced             budgetary control            recommendations. DOH indicators (Oct 06)
      balance                                                                                                                                                                                                                                   treatment of SHA £2.8M for
                                                                                                WFP being implemented. CEO checking                                           agency costs low. IA 01.06/07 adequate
                                                                                                                                                                                                                                               2006/0. ALE score for use of
                                                                                                     the sign off letters received from                                        assurance on private patient income
                                                                                                                                                                                                                                                 resources: weak (July 06)
                                                                                                managers and holding people to account
                                                                                                              for non delivery

                                                                                                                                                                               IA report 17.2006/07 (Nov 06):adequate
                                                                                                                                                                         assurance re charitable funds; IA report 08.05/06
                                                                                                                                                                         (Nov 2005) : substantial assurance re SLA's. IA
                                                                                                                                                                               report (02.05/06) (Nov 2005) : adequate
                                                                                                                                                                           assurance re pharmacy stocks & stores. IA top
Achievement of the                                                                                 Weekly turnaround project Delivery                                                                                                             IA report 06.06/07 : staff
                                                                                                                                                                                up testing report 24.2005/06 (Apr 06) :
Financial Recovery                                                                                 Group Project Board reports to TB     Internal and External reporting                                                                              expenses - limited
                                                                                                                                                                             substantial assurance on payroll IA report
Plan within a robust                                                                              Workstreams SFIs and Scheme of           Senior management review                                                                              assurance on formulation,
                                                                                                                                                                           13.05/06 (Nov 2005) : reasonable progress re
    performance                        Waste, inefficiency,                                         Delegation        Financial control    Performance Management                                                                              dissemination and application
                                                                                   FD                                                                                       estates stocks & stores. IA report 01.2005/06
   management        C7a               extravagance, fraud      16                               systems and reporting           Counter   Internal and External Audit                                                                          of travelling expenses policy
                                                                                Financial                                                                                   (Aug 05) : substantial assurance re losses &
framework to bring                          and error                                           Fraud Arrangements CEO checking the including ALE assessment Local                                                                                   IA reports 03.06/07
                                                                                                                                                                             compensations IA report 15.05/06 (Feb 06) :
   the Trust into                                                                               sign off letters received from managers Counter Fraud Specialist Annual                                                                            &04.06/07 gave limited
 recurrent financial                                                                             and holding people to account for non        Report Internal audit         adequate assurance re capital programme &
                                                                                                                                                                                                                                                 assurance about medical
      balance                                                                                                     delivery                                                asset management. IA report 14.06/07 system of
                                                                                                                                                                                                                                                        devices loans
                                                                                                                                                                            control for pharmacy stock usage sufficiently
                                                                                                                                                                         robust IA report 06.06/07 : adequate assurance
                                                                                                                                                                               on processing of travel claims. IA report
                                                                                                                                                                          07.06/07: adequate assurance on cash & bank.
                                                                                                                                                                                     LCFS annual report (June 06)


                                                                                                                                                                           IA 11.06/07 departmental review Maternity & IA
                                                                                                                                                                             16.06/07 departmental review Surgery gave
                                                                                                                                                                           adequate assurance on compliance with SFIs


                                                                                            Turnaround projects and plans Detailed
                                                                                                  weekly and monthly cash flow
Achievement of the                                                                                                                                                       IA reports 04.2005/06 (Aug 05) & 18.2005/06 (Jan
                                                                                            projections and cash strategy considered
Financial Recovery
                                                                                            by Finance Committee, Trust Board and                                          06) provide substantial assurance re Income
Plan within a robust
                                        Failure to achieve                                   SHA via FMR return. Deferral of trade                                       systems & Debtors. IA report 20.2005/06 (Feb 06)
    performance                  178                                                                                                   Internal Audit work in respect of
                                         CIP and lack of                                         creditors least likely to cause an                                          provides substantial assurance re creditor
   management        C7d         177                            25             FD Financial                                               cash and banking, creditor
                                        knowledge about                                          operational issue. Ensure timely                                           payments IA 10.06/07: adequate assurance
framework to bring               140                                                                                                  payments and billing and debtors
                                          effect of PBR                                        collection of all income owing to the                                       about PBR activity data IA 13.06/07 adequate
   the Trust into
                                                                                               Trust to minimise the shortfall. CEO                                          assurance on procurement (input & output
 recurrent financial
                                                                                               checking the sign off letters received                                                         controls)
      balance
                                                                                              from managers and holding people to
                                                                                                     account for non delivery



January 07                                                                                                                      Shaded areas indicate recent changes                                                                                                   1 of 5
Appendix 1                                                                                                                                                                                                                                                 Board Assurance Framework
PRINCIPAL
OBJECTIVES         S4BH                      PRINCIPAL RISKS                                               KEY CONTROLS                                            ASSURANCES ON CONTROLS                                                                 GAPS
                                                                               Lead Director




                                                               residual risk
                   Healthcare
                                                                                      +
                                                                                                                                                                                                                                                             gaps in assurance ie




                   Standard
                                                                               Classification
   Operational                  CRR                                                                                                                                            positive assurances received in last 18                                      negative / limited or no




                                                              score
                                                                                of principal
   Objectives                   Ref      Principal Risks                            risk                       Controls                    potential sources of assurance                  months (date)                          gaps in control              assurance (date)
                                                                                                                                                                                                                              Director of Strategy and
                                                                                                    Strong links with West Midlands       West Midlands Strategic Health
                                      Lack of engagement                                                                                                                                                                         Head of Marketing
                                                                                  CEO           Strategic Health Authority, Overview and Authority Scorecard outcomes
                                177      with external                                                                                                                                                                              Measures of
                                                                                Corporate         Scrutiny Committee, PPI Forum and        (expected 06/07) Strategic
                                         stakeholders                                                                                                                                                                         understanding of issues
                                                                                                                  PCT                    Service Review (expected 06/07)
                                                                                                                                                                                                                              externally and internally


                                                                                                                                                                                                                              Lack of strategy. Lack of
                                         Lack of clear                            CEO                                                      Approved marketing strategy and
                                                                                                         Current LDP process                                                                                                  engagement with GPs /
                                       marketing strategy                       Corporate                                                          review process
                                                                                                                                                                                                                                        PCTs


                                                                                                  Integrating Governance Strategy and       HCC Annual Health Check (Oct
                                                                                                Action Plan Principal objectives set and   06) Assurance Framework. Risk
                                                                                                agreed at Board level and communicated     Register Updates. Internal Audit.
                                                                                                   to all staff. Risk Assessment. Risk       Statement of Internal Control.
Trust to have sound                    Board capacity /                                                                                                                                                                       Director of Strategy and
                                                                                  CEO             Register. Reporting of risks to Board     Board agendas. Internal audit
    governance      C7a               governance to meet                                                                                                                     Annual Healthcheck - Quality of Services Good       Head of Marketing
                                                                                Corporate        through Audit Committee, SGC and TB                review of Risk
   arrangements                           FT criteria                                                                                                                                                                           Company Secretary
                                                                                                     Performance Framework. Risk               Management/Assurance
                                                                                                  Management Strategy. Performance             Framework Internal audit
                                                                                                 management process Annual business          Statement of Internal Control
                                                                                                                     plan                             (June 07).


                                                                                                                                                                                                                               lack of organisational
                                                                                                                                                                                                                                structure and robust
                                          Weak clinical                                                                                                                                                                       reporting framework to
Trust to have sound
                                         involvement &                         CEO / MD                                                                                                                                             ensure greater
    governance      C7a         274                                                              Existing clinical management structure
                                          management                           Corporate                                                                                                                                          engagement New
   arrangements
                                            capacity                                                                                                                                                                            clinical management
                                                                                                                                                                                                                               structure - in place by
                                                                                                                                                                                                                                      March 07


                                                                                                  Principal objectives set and agreed at    Assurance Framework. Risk
                                                                                                  Board level and communicated to all     Register Updates. Internal Audit.                                                                               Taylor Sellers report (Sep 05)
                                                                                                staff. Risk Assessment. Risk Register.      Statement of Internal Control. IA reports 12.05/06 (Nov 05) & 33.05/06 (Apr 06)                                  highlighted significant
                                                                                                Reporting of risks to Board through Audit Board agendas. Internal audit        give substantial assurance on the Trust's                                   failings in 2004/05. Action
Trust to have sound                    Lack of integrated
                                                                                  CMD            Committee, SGC and TB Performance                 review of Risk            assurance framework. IA report 18.0607 said                                     Plan presented to Trust
    governance      C7a                   approach to
                                                                                Corporate            Framework. Risk Management               Management/Assurance          good progress has been made in implementing                                    Board November 2005 and
   arrangements                           governance
                                                                                                 Strategy. Performance management             Framework Internal audit           the recommendations of the Integrated                                     each Audit Committee and
                                                                                                process Annual business plan Revised        Statement of Internal Control                Governance Handbook                                               Strategic Health Authority.
                                                                                                     Committee Structure Integrated       (June 07). Annual Health Check                                                                                    Most actions completed.
                                                                                                          Governance Strategy               NHSLA assessment (Dec 06)


                                          Not improving
                                                                                                      Turnaround projects and plans
                                      productivity and cost
                                                                                                incorporating modernisation and benefits
                                         effectiveness to
                                                                                                  realisation CEO checking the sign off
                                        ensure Trust can
                                                                                                   letters received from managers and
                                      continue to compete
                                                                                                    holding people to account for non
                                       and secure revenue
                                                                                                                  delivery
                                              flows


                                       Failure to project
                                          manage the
                                                                                                                                                                                                                               Dedicated FT lead - to
                                      application process                         CEO
                                                                                                        FT action plan in place                                                                                                  include in remit of
                                      and not fully engage                      Corporate
                                                                                                                                                                                                                                Director of Strategy
                                      with DoH/ Monitor’s
                                         requirements.
January 07                                                                                                                        Shaded areas indicate recent changes                                                                                                            2 of 5
Appendix 1                                                                                                                                                                                                                                                    Board Assurance Framework
PRINCIPAL
OBJECTIVES         S4BH                      PRINCIPAL RISKS                                              KEY CONTROLS                                            ASSURANCES ON CONTROLS                                                                     GAPS
                                                                              Lead Director




                                                              residual risk
                   Healthcare
                                                                                     +
                                                                                                                                                                                                                                                                gaps in assurance ie




                   Standard
                                                                              Classification
   Operational                  CRR                                                                                                                                             positive assurances received in last 18                                        negative / limited or no




                                                             score
                                                                               of principal
   Objectives                   Ref     Principal Risks                            risk                       Controls                   potential sources of assurance                     months (date)                            gaps in control              assurance (date)

CO2 To achieve all key national targets and priorities on an annual basis

                                 21
                                                                                               Performance Framework documentation
                                222                                                                                                                                         Healthcare Commission Annual Health Check:
                                                                                                 & process Divisional review process                                                                                           Review of measures to
                                 67                                                                                                                                        National Targets: fully met new national targets:
                                                                                                       Rigorous bed management               Performance report to Trust                                                       reduce reliance on 'out
                                154    Changing targets                                                                                                                       good IA 12.06/07 adequate assurance on                                      Healthcare Commission
                                                                                                     arrangements Weekly waiting          Board giving key national access                                                   of hours' / ad hoc activity
   Meet all NHS    C7f          167    and priorities may                        COO                                                                                           Patient Access System (PAS) IA 09.06/07                                   diagnostic services review
                                                               20                                  list/performance meetings Exec         targets Weekly SITREPS return                                                       to achieve targets Co-
     targets       C19          169     lead to failure to                     Corporate                                                                                      substantial assurance on Choose & Book                                          and admissions
                                                                                               Director sign off of statutory submissions IA reports Annual Health Check                                                        ordinated system for
                                200    meet NHS targets                                                                                                                      implementation. DOH indicators on day case                                  management. Fair (Oct 06)
                                                                                                Daily waiting list produced for divisions            (Sept 06)                                                               controlling medical staff
                                209                                                                                                                                         rates, length of stay and pre-op bed stays good
                                                                                               Regular validation of patients on waiting                                                                                                leave
                                271                                                                                                                                                              (Oct 06)
                                                                                                                    list
                                 69

                                       Lack of Corporate
                                                                                 CEO              KSF linking appraisal to corporate                                                                                              Divisional staff survey
                   C7a                    culture and                                                                                    Staff survey Exit questionnaires                                                                                           Staff survey results
                                                                               Corporate                      objectives                                                                                                               action plans
                                          motivation

                                                                                                 Weekly turnaround project Delivery
                                       Lack of demand                                                                                                                                                                                Links with external
Reduce patient flow D11         261                                             COO              Group Project Board reports to TB       Patient survey to measure patient                                                                               Performance reports indicate
                                       management and                                                                                                                                                                               stakeholders eg GP
 and length of stay  d          270                                           Operational        Workstreams with Exec leads and         satisfaction Performance reports                                                                                over performance on activity.
                                       capacity issues                                                                                                                                                                            communication network
                                                                                                           project plans

                                                                                                                                                                                                                                   lack of organisational
                                                                                                                                                                                                                                    structure and robust
                                          Weak Clinical                                                                                                                                                                           reporting framework to
                                                                                                                                                                             Report on DOAS (Maternity IT project) and letter
                                         involvement &                        CEO / MD                                                                                                                                                  ensure greater
                   C7a                                                                          Existing clinical management structure                                       from Prof. Muir Grey praising clinical involvement
                                          management                          Corporate                                                                                                                                               engagement New
                                                                                                                                                                                                 (Sep 06)
                                            capacity                                                                                                                                                                                clinical management
                                                                                                                                                                                                                                   structure - in place by
                                                                                                                                                                                                                                          March 07

                                      Differential targets                        FD            System for managing differential waits
                   C18                                                                                                                         Performance reports
                                      for Welsh patients.                      Financial                      SLA's

CO3 To recognise and enhance, through organisational development, the contribution of the workforce to the success of the organisation

                                                                                                                                                                                                                                   lack of organisational
                                                                                                                                                                                                                                    structure and robust
                                      Clinicians and wider
                                                                                                                                                                                                                                  reporting framework to
                                          trust not fully
                                                                              CEO / MD                                                                                                                                                  ensure greater
                   C7a                   engaged in the                                         Existing clinical management structure
                                                                              Corporate                                                                                                                                               engagement New
                                         strategic Trust
                                                                                                                                                                                                                                    clinical management
                                             agenda
                                                                                                                                                                                                                                   structure - in place by
                                                                                                                                                                                                                                          March 07

  Rationalise and   C11
                                                                                               Performance management, appraisal &
  standardise all    a                                                                                                                     Royal Colleges CNST Staff         IWL Practice Plus achieved (Jan 06) CNST level  Trust wide training
                                      Failing to skill and                                        PDP processes, recognizing and
   training and     C11                                                          CMD                                                         survey results Clinical           2 Maternity (Dec 05) CNST General Level 2    needs analysis, Trust
                                284       develop the                                          rewarding success Clinical Governance                                                                                                                            Annual Training Report
development needs b                                                               HR                                                       Governance Annual report          (March 06) Staff Survey (March 06) Supervisor Wide training strategy,
                                           workforce                                             Development Plan D&T manager in
and activity across C11                                                                                                                   Supervisor of Midwives Report               of Midwives Report (Aug 06)           plan and prospectus
                                                                                                     place to coordinate activity
     the Trust.      c




January 07                                                                                                                     Shaded areas indicate recent changes                                                                                                                        3 of 5
Appendix 1                                                                                                                                                                                                                                                      Board Assurance Framework
PRINCIPAL
OBJECTIVES           S4BH                      PRINCIPAL RISKS                                              KEY CONTROLS                                             ASSURANCES ON CONTROLS                                                                    GAPS
                                                                                Lead Director




                                                                residual risk
                     Healthcare
                                                                                       +
                                                                                                                                                                                                                                                                  gaps in assurance ie




                     Standard
                                                                                Classification
   Operational                    CRR                                                                                                                                             positive assurances received in last 18                                        negative / limited or no




                                                               score
                                                                                 of principal
   Objectives                     Ref     Principal Risks                            risk                       Controls                  potential sources of assurance                      months (date)                            gaps in control              assurance (date)

                                          Failure to develop                                     Established Shropshire-wide group to co-
                                         comprehensive and                                       ordinate integration of capacity planning,
                                  193         meaningful                                           service modernisation and workforce                                          Reduced WFP presented to TB and managers
                     C22                                                                                                                    Workforce plans reflect capacity
 Realise workforce                231       workforce and                          CMD                planning Established training                                            Nov 05. On target July 06 Implementation plans                                    'Birthrate plus' highlighted
                      c                                          25                                                                          plans and financial position
  reduction plans                 192   succession planning                         HR              programme for managers GRASP                                                being drawn up and monitored through finance                                   shortage of 11 wte midwives;
                     D7                                                                                                                        EWTD 'new deal' returns
                                  223     linked to capacity                                     workload tool; contingency plans Action                                                          meetings.
                                             planning and                                         plan to address Workforce analyst in
                                             affordability                                                          post


                                                                                                 Health and Safety legislation, procedures
                                                                                                   and guidance Occupational Health;
                                                                                                                                              Occupational Health referral
                                                                                                   COSHH ; incident reporting Manual
                                                                                                                                             numbers, Counselling referral
                                        Failure to provide a                                        handling training and policies; New
                                   52                                             CMD                                                         numbers, number of policy
 Meet Health and     C20                 safe and healthy                                        sickness policy (TB July 05) Training for                                                                                                                      Staff survey results. Action
                                  244                            16              Health &                                                  breaches Incident reports Health        Health & Safety Annual Report (Sept 06)
 Safety Standards     a                       working                                             managers Conflict resolution training;                                                                                                                              plan developed.
                                   46                                             Safety                                                       and Safety Annual Report
                                            environment                                            Security Guards, Reporting system;
                                                                                                                                            Reported incidents Staff survey
                                                                                                 Protocols with Police Security Manager
                                                                                                                                                        results
                                                                                                  Security management policy approved
                                                                                                                   Nov 05


                                           Failure to link
                                              personal
Full implementation                       development to                                            KSF linking appraisal to corporate     Staff survey Exit questionnaires                                                          Divisional staff survey
                    D7                                                           CMD HR                                                                                          KSF reviewed at quarterly review meetings.                                           Staff survey results
       of KSF                              organisational                                                       objectives                           KSF returns                                                                          action plans
                                         development and
                                        corporate objectives

CO4 To continue to improve patient safety and the patient experience

                       5 49
                        234
                         1
                        249              Failure to address                                       Capital planning group Risk Register
                                                                                  COO
Improve on patient C20 242                  estates issues                                           Backlog priorities established           Incident reporting Patient        P21 Partner selected (TB May 05). No serious
                                                                 25              Health &
  survey results    a    86               including known                                        Coordinated programme of replacement                   surveys                    incidents reported year to date (Nov 06)
                                                                                  Safety
                        283                      risks                                                       of infrastructure
                        281
                        275
                        279

                                  237     Failure to adopt
                                        strategic approach
                                             to patient                                                                                                                         Acute Hospital Portfolio - satisfactory rating of
                                                                                   CMD                                                                                                                                                                          Patient Survey Results (May
Develop action plan                      involvement and                                         PPI Strategy & Action Plan approved by                                        patient experience in A&E; good rating for ward
                    D8                                                            Patient                                                           Patient survey                                                                                                  06) show decline in
 for patient survey                       gain support of                                                    Board June 06                                                     staffing audit. (AC July 05) Patient Survey results
                                                                                  Focus                                                                                                                                                                         performance in some areas
                                               patient                                                                                                                                            (TB April 05)
                                        groups/community
                                                reps.

                                                                                                 Risk Management Strategy and incident                                         CNST level 2 General (March 06) and Maternity
Trust to have sound                       Ineffective risk                                                                                  NHSLA assessment (Dec 06)
                                                                                   CMD           reporting policies Risk Register Group                                        (December 05) Peer review of Critically Ill Child
    governance      C7c                    management                                                                                        CNST Maternity (June 07)
                                                                                 Corporate        New committee structure with Clinical                                           (Nov 05) highlighted incident reporting and
   arrangements                              strategy                                                                                             Internal Audit
                                                                                                    Governance Executive led by MD                                              feedback mechanisms as area of good practice




January 07                                                                                                                        Shaded areas indicate recent changes                                                                                                                       4 of 5
Appendix 1                                                                                                                                                                                                                                              Board Assurance Framework
PRINCIPAL
OBJECTIVES         S4BH                      PRINCIPAL RISKS                                              KEY CONTROLS                                              ASSURANCES ON CONTROLS                                                             GAPS
                                                                              Lead Director




                                                              residual risk
                   Healthcare
                                                                                     +
                                                                                                                                                                                                                                                          gaps in assurance ie




                   Standard
                                                                              Classification
   Operational                  CRR                                                                                                                                           positive assurances received in last 18                                    negative / limited or no




                                                             score
                                                                               of principal
   Objectives                   Ref     Principal Risks                            risk                        Controls              potential sources of assurance                       months (date)                         gaps in control             assurance (date)
                                                                                               Guidelines SUI reporting system Group
                                150
                                          Delays in                                                  established with Stoke Trust
                                 38
                   D1               transferring patients                        MD              involvement in health economy-wide                                                                                             Compliance with
                                191                                                                                                   Incident reports Audit reports         Clinical Audit report on Head Injury transfer
                   C5a              to appropriate health                       Clinical           group set up by UNHS Improved                                                                                             protocols for transfers
                                 41
                                          facilities                                           communication with UNHS CE involved
                                277
                                                                                                           in ongoing issues

                                                                                                                                                                            Annual Healthcheck - Core standards fully met
                                 50    Failure to comply                                       Monitoring by performance assessment
                                                                              CMD COO                                                       Annual health check External     Reasonable system in place - Internal audit                                  Annual Health Check.
                                 55     with healthcare                                         Group New committee structure with
                   C7a                                                           MD                                                         comments - StHA, OSC, PPI       report (Nov 05) Annual Health Check (Oct 05)                                 Reviews of services for
                                185    commission core                                          Clinical Governance Executive led by
                                                                              Corporate                                                                Forum               Medicines Management : Excellent. Peer review                                 children in hospital - fair
                                280        standards                                                             MD
                                                                                                                                                                                      of critically ill child (Dec 05)


                                      Poor communication                         CMD
                                                                                               PPI Strategy & Action Plan Community
                    D8                 with patients and                        Patient                                                            Patient survey
                                                                                                          Advisory Group
                                             carers                             Focus


                                                                                                                                                                             CNST level 2 achieved in General Standards
                                      Not having effective                                                                                                                                                                   Development of clinical
                                                                                                                                                                           (March 06) and Maternity Standards (Dec 05) IA
                                221   clinical governance                        MD             Establishment of Clinical Governance                                                                                         governance indicators MHRA blood bank inspection.
                                                                                                                                                                           02.06/07 positive survey of incident reporting IA
                                272        and related                          Clinical       Executive as part of meeting re-structure                                                                                      Outputs from Clinical   Critical report Oct 06
                                                                                                                                                                            05.06/07 gave adequate assurance on policies Governance meetings
                                           processes.
                                                                                                                                                                                           and procedures

                                                                                                                                                                            Information Governance score increased (July
                                                                                                                                                                              06). IA 32.05/06 demonstrated reasonable                                  IA 35.05/06 little progress
                                                                                                 Information Governance policies and
                                                                                                                                                                             progress on PRH wireless LAN. IA 36.05/06                                     on implementation of
                                                                                                             procedures
                                                                                                                                                                             demonstrated reasonable progress on data                                    recommendations of Data
                                                                                                                                                                                         back-up and recovery                                               Protection Act Audit
                           .
CO5 To achieve Teaching Hospital status

                                       Failure to achieve
                                                                                                                                                                                                                             Lack of regular reports
                                             UGMS                                MD            Project group Contingency plans phased Outline Business Case (TB Sept
                                253                            16                                                                                                    Outline Business Case accepted by TB (Sept 06)            to Trust Board on
                                        accommodation                           Estates             approach Project management                     06)
                                                                                                                                                                                                                                    progress
                                         requirements

   Ensure staff
                                        Lack of clinical                                                                                                                                                                           New clinical
 involvement and                                                                  MD                                                                                        Feedback from Manchester medical students
                                255   commitment/leaders       16                                   clinical management structure                                                                                            management structure -
 commitment into                                                               Corporate                                                                                        giving Trust highest rating (July 06)
                                             hip                                                                                                                                                                              in place by March 07
  Medical School

   Ensure staff                        Failure to consider
                                                                                                                                                                                                                             Lack of regular reports
 involvement and                      impact of UGMS on                       COO & MD Project group Contingency plans phased Outline Business Case (TB Sept
                                256                            16                                                                                            Outline Business Case accepted by TB (Sept 06)                    to Trust Board on
 commitment into                        Trust operational                     Operational   approach Project management                     06)
                                                                                                                                                                                                                                    progress
  Medical School                             issues

                                       Failure of external                                                                                                                                                                   Lack of regular reports
                                                                                  MD
                                255   partnership working      16                               Project Board and programme updates                                                                                            to Trust Board on
                                                                               Corporate
                                        (eg HEIs, PCTs)                                                                                                                                                                             progress


                                         Lack of clearly
                                                                                                                                                                                                                             Lack of regular reports
                                       identified funding                         FD                                                       Outline Business Case (TB Sept
                                255                            16                                                                                                         Outline Business Case accepted by TB (Sept 06)       to Trust Board on
                                        streams to fully                       Financial                                                                 06)
                                                                                                                                                                                                                                    progress
                                         deliver project




January 07                                                                                                                      Shaded areas indicate recent changes                                                                                                             5 of 5

								
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