Initial Risk Management Strategy

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					            MASTER                                               RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK - Updated 8/11/2007                                                                               APPENDIX 'B'




Objective              Risk                                Mapped Initial      Current Control          Gaps in Control          Current Assurance         Gaps in Assurance            Action Required         Residual   Lead
                                                           to HCC   Risk                                                                                                                                        Risk       Director
                                                           Standard Rating                                                                                                                                         (C x    Review
                                                           s          (C x L =                                                                                                                                  L = )      Date
                                                                    )
What the organisation What could prevent this objective e.g. C1(a)             What controls/ systems   Where we are             Where we can gain         Where we are failing to      What needs to be
aims to deliver       being achieved                                           we have in place to      failing to put           evidence that our         provide evidence that        carried out to reduce
                      RR=Risk Register                                         assist in securing       controls / systems       controls/ systems, on     our controls /               the risk. By when
                                                                               delivery of our          in place                 which we are placing      assessments are
                                                                               objectives.                                       reliance are effective    effective

    STRATEGIC OBJECTIVE                                    1. TO IMPROVE THE HEALTH AND WELL BEING OF THE ROTHERHAM POPULATION
1A To reduce health    Unlikely to meet the reduction in   C22       L=5       NST Action Plan          1) NST Action Plan       1) NST Action Plan        Mortality data not "real     Fully implement the     L=4        JR Mar 08
inequalities - 2010    the gap of life expectancy                    C=4                                not yet fully            reports to Board          time"                        NST Action Plan         C=4
targets short term     required to meet 2010 target as               RR=20                              implemented              quarterly                                                                      RR=16
                       the amount of improvement is                   RED                                    2) Some                 2) 3 year average                                                          RED
                       not in line with national                                                        trajectories are         mortality updates
                       trajectories (i.e. speed).                                                       beyond PCT control
                                 Risk Register 215                                                      e.g. Poverty


1B To reduce health    Despite interventions i.e. NST      C22       L=4       Rotherham Public         1) Public Health         1) Reports to LSP via     Reports to PCT Board         Review reporting        L=3        JR Mar 08
inequalities in the    action Plan the gap in                        C=4       Health Strategy          Strategy not yet fully   Alive Board.                                           mechanisms              C=4
medium to long term    inequalities is not closing.                  RR=16                              implemented              2) Annual DPH Report                                   Continue to work        RR=12
                                                                     RED                                 2) Health Services                  3) Internal                                with partner            Amber
                                      Risk Register 216                                                 not the major            monitoring group                                       organisations
                                                                                                        determinant -            established
                                                                                                        depends on
                                                                                                        economic
                                                                                                        performance/partner
                                                                                                        ship etc

1B To reduce health    Inequitable use of funding -                0 L=3       Contract compliance      No systematic      Report to LSP                                              0 Need a systematic               0 KA/JR
inequalities in the    manage contracts to target                     C=4      Review of progress       process to measure                                                              process to identify               CS
medium to long term    resources to areas of need.                    RR=12    between areas            compliance by                                                                   and compare                       Mar 08
                                                Risk                   RED                              target group area                                                               investment &
                       Register 217                                                                                                                                                     outcome between
                                                                                                                                                                                        areas and a process
                                                                                                                                                                                        for actioning change




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            MASTER                                                 RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK - Updated 8/11/2007                                                                          APPENDIX 'B'




Objective                Risk                                Mapped Initial      Current Control            Gaps in Control       Current Assurance          Gaps in Assurance        Action Required        Residual   Lead
                                                             to HCC   Risk                                                                                                                                   Risk       Director
                                                             Standard Rating                                                                                                                                    (C x    Review
                                                             s          (C x L =                                                                                                                             L = )      Date
                                                                      )
1C Safeguarding          Emergency response of the PCT C24             L=3       1) Annual Plan agreed      Unable to determine 1) Joint Health & Social None                         Ongoing actions        L=2        JR Dec 08
Health in Emergency      inadequate.                                   C=5       by the Board covering      all types of        Care Emergency                                                               C=5
Planning / Service        Risk Register 218                            RR=15     most contingencies         emergency faced by Planning Group in place                                                       RR=10
Continuity                                                             RED                  2)Emergency     the PCT                                 2)                                                       Amber
                                                                                 Planning tested                                PCT Planning Group.
                                                                                 annually and reviewed                                           3)
                                                                                 in recent emergencies                          Board receive an
                                                                                                                                annual update on
                                                                                                                                Emergency Planning.


1C Safeguarding          Emergency response of the PCT C24             L= 5      Local Risk Register        Reporting          1) PCT Emergency              Mechanisms for           Review reporting       L=2        JR Dec 08
Health in Emergency      does not consider risks identified            C=4       developed in relation to   mechanisms for     Planning Group                reporting to PCT Board   mechanisms             C= 4
Planning / Service       throughout the health                         RR = 20   the South Yorkshire        emergency planning    2) Joint health &                                   Continue to work       RR=8
Continuity               community.                                    RED       Risk Register. Agreed      risk register      social Care PCT                                        with partner           Amber
                                   Risk Register 219                             by PCT Emergency                              Emergency Planning                                     organisations
                                                                                 Planning Groups                               Group


1C Safeguarding           Risk in relation to lack of        C24       L= 5      Local Risk Register        In relation to        Use of Satellite           To ensure the PCT and    Generator plan to be L=2          JR Dec 08
Health in Emergency      generator back up in key                      C=4       developed in relation to   generator Head of     telephone technology       NHS in Rotherham is      developed by         C= 4
Planning / Service       buildings. (RPCT Risk register                RR = 20   the South Yorkshire        Estates to write a    with a 3k grant from the   represented at the       November 2007.       RR=8
Continuity               for Emergency Planning).                      RED       Risk Register. Agreed      Generator action      SHA. Head of Estates       RMBC fuel strategy                            Amber
                                           Risk Register                         by PCT Emergency           plan by November      coordinating purchasing    meeting as they know
                         220                                                     Planning Groups            2007. Possible        and installation           how to coordinate all    Attendance at Fuel
                                                                                                            generators to be                                 essential users in       strategy meeting by
                                                                                                            sought for Oak                                   Rotherham                a representative
                                                                                                            House and the new                                                         from NHS estates
                                                                                                            PCC. Fuel - Head of
                                                                                                            Estates to attend
                                                                                                            fuel management
                                                                                                            meetings led by
                                                                                                            RMBC on behalf of
                                                                                                            the NHS




    STRATEGIC OBJECTIVE                                      2. TO IMPROVE HEALTH SERVICES ACROSS ROTHERHAM
2A To deliver existing Insufficient contracted activity to   C7f       C=4       FACT use internal and      None                  Board Performance          None                     None                   C=4     CS
and new national       meet the targets.                                 L=3     external models to                               Report                                                                       L = 2 MAR 08
targets                Risk Register 221                                         calculate required
                                                                       RR = 12   activity.                                                                                                                   RR = 8
                                                                        RED
                                                                                                                                                                                                             AMBER




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            MASTER                                               RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK - Updated 8/11/2007                                                                  APPENDIX 'B'




Objective                Risk                              Mapped Initial      Current Control          Gaps in Control     Current Assurance         Gaps in Assurance     Action Required        Residual   Lead
                                                           to HCC   Risk                                                                                                                           Risk       Director
                                                           Standard Rating                                                                                                                            (C x    Review
                                                           s          (C x L =                                                                                                                     L = )      Date
                                                                    )
2A To deliver existing Service providers fail to deliver   C7f       C=4       Monthly monitoring of    None                Board Performance         None                  Develop potential     C=4         CS
and new national       contracted requirements.                      L=3       contracts by FACT                            Report                                          alternative providers    L=       MAR 08
targets                Risk Register 222                             RR = 12                                                                                                and capacity.         2
                                                                      RED                                                                                                                          RR = 8

                                                                                                                                                                                                   AMBER

2A To deliver existing Services are not redesigned         C7f       C=3       18 Week Group review     None                18 Week Group reports     None                  Incorporation of       C=3        CS
and new national       where appropriate.                            L=4       of services.                                 to Directors.                                   redsign work into          L=     MAR 08
targets                Risk Register 223                             RR = 12                                                                                                mainstream             3
                                                                     AMBER                                                                                                  commissioning           RR = 9
                                                                                                                                                                            processes.
                                                                                                                                                                                                   AMBER

2A To deliver existing LDP fails to allocate necessary     C7f       C=4       LDP group makes          None                Board Performance         None                  Review of the LDP      C=4     CS
and new national       resources to key target areas.                L=4       recommendations to                           Report                                          processes.                L = MAR 08
targets                Risk Register 224                             RR = 16   Directors, PE and then                                                                                              3
                                                                     RED       the Board                                                                                                           RR = 12
                                                                                                                                                                                                      RED

2A To deliver existing Obesity - Service provision does    C23       L=5       1) Choosing Health       Monitoring of       Monitoring of Obesity     Plan not fully        Reflected in future    L=5        JR Mar 08
and new national       not currently meet need.                      C=4       Delivery Plan            Obesity Strategy    Strategy and L.D.P.       implemented yet       LDPs                   C=4
targets                                  Risk                        RR=20     2) Obesity strategy      and L.D.P.                                                                                 RR=20
                       Registered 225                                RED              3) Procurement                                                                                                RED
                                                                               Process
2A To deliver existing Unplanned care requirements                 0 L=3       Activity monitoring by   Lack of real time   Activity monitoring       None                  More timely            C=4     KA
and new national       continue to escalate.                            C=4    FACT                     management of       reports to PE & Board                           monitoring of activity     L=2 Mar 08
targets                      Risk Register 227                                                          activity                                                            and cause of
                                                                     RR=12                                                                                                  unplanned activity     RR=8
                                                                     RED                                                                                                                           AMBER

2A To deliver existing Patient Choice & booking            C18       C=3       Close monitoring of      None                Regular reports to PE &                       0 Ongoing plan to        C=3        KA
and new national       arrangements not delivered.                   L=4       targets by Choose &                          Board                                           identify further          L=3     Mar 08
targets                   Risk Register 226                           RR=12    Book team                                    National surveys                                action needed
                                                                                                                                                                                                   AMBER
                                                                     AMBER




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            MASTER                                                   RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK - Updated 8/11/2007                                                                       APPENDIX 'B'




Objective                 Risk                                 Mapped Initial      Current Control          Gaps in Control      Current Assurance        Gaps in Assurance        Action Required          Residual   Lead
                                                               to HCC   Risk                                                                                                                                Risk       Director
                                                               Standard Rating                                                                                                                                 (C x    Review
                                                               s          (C x L =                                                                                                                          L = )      Date
                                                                        )
2B To effectively         Commissioning decisions are not C7d            C=4       Skilled contracting team None                 Monthly meeting          None                     Contracting skills to    C=4     CS
commission first          incorporated into contracts with               L=4       are kept up to date of                        between FACT and                                  be developed and            L = MAR 08
class services for        the required levers and                        RR = 16   commissioning                                 Strategic Development.                            up dated regularly.      3
Primary, Secondary        flexibilities.                                 RED       intentions.                                                                                                              RR = 12
and Tertiary Services,    Risk Register 228                                                                                                                                                                    RED
including out of hours
and emergency care
e.g. Commissioning
for patient experience.




2B To effectively         The market does not have             C7f       C=3       Commissioning              None               Y&H meetings (annual     None                     Prepare a market       C=3          CS
commission first          providers available to deliver the             L=3       intentions are notified to                    review, CE, DOFs)                                 development               L=        MAR 08
class services for        required level of services.                    RR = 9    the main providers for                        provide evidence of                               strategy to align with 2
Primary, Secondary        Risk Register 229                              AMBER     them to develop as                            market providers                                  the commissioning       RR = 6
and Tertiary Services,                                                             needed .                                      available elsewhere.                              intentions.
including out of hours                                                                                                                                                                                      YELLOW
and emergency care
e.g. Commissioning
for patient experience.




2B To effectively         Current commissioning strategy               0 L=5       Enhancement of quality   Some standards       Board reports            Current Board reports    Define standards      L=3           CS/JR
commission first          emphasizes numbers and                         C=3       standards and            developed however                             have more information    agree the process     C=5           Mar 08
class services for        waiting times rather than patient              RR=15     monitoring in            further work on                               on volume than quality   for monitoring ,      RR=15
Primary, Secondary        experience and quality. The                     RED      commissioning            more standards                                                         ensure they're in the RED
and Tertiary Services,    standards are required to ensure                                                  need to be                                                             contract and monitor
including out of hours    the information is available for                                                  undertaken not yet                                                     against them
and emergency care        the next round of contracting.                                                    in place
e.g. Commissioning                           Risk Register
for patient experience.   230




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            MASTER                                                 RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK - Updated 8/11/2007                                                                     APPENDIX 'B'




Objective                Risk                               Mapped Initial      Current Control           Gaps in Control     Current Assurance        Gaps in Assurance          Action Required       Residual   Lead
                                                            to HCC   Risk                                                                                                                               Risk       Director
                                                            Standard Rating                                                                                                                                (C x    Review
                                                            s          (C x L =                                                                                                                         L = )      Date
                                                                     )
2B To effectively       Financial implications -High cost   C 7a      L=3       1) PAG & Continuing       None                Reports to PE & Board    None                       New data base         C=4        KA
commission first        of individual placements            C 18       C=4      Care process in place                         as part of key targets                              being developed in    L=2        MARCH 08
class services for      (continuing care and PAG).          C 19       RR=12                                                                                                      Continuing Care.
Primary, Secondary                                          D 11          RED                                                                                                                Further
and Tertiary Services,          Risk Register 231                                                                                                                                 training on           RR=8
including out of hours                                                                                                                                                            implementation of
and emergency care                                                                                                                                                                new Continuing        AMBER
e.g. Commissioning                                                                                                                                                                Care criteria
for patient experience.




2B To effectively       PCT not able to identify            C7a       L=3       Contract monitoring and                     0 Target report to Board                             0 Integrated           C=3        KA
commission first        disengage from PC or contracts.      C18      C=4       action required                               monthly                                              management &                      Mar 08
class services for                                            C19     RR=12                                                   Exceptions reporting                                 monitoring of         L=2
Primary, Secondary            Risk Register 232                D11      RED                                                                                                        contracts
and Tertiary Services,
including out of hours                                                                                                                                                                                  YELLOW
and emergency care
e.g. Commissioning
for patient experience.




2 C To meet National     The organisation does not         All        L=3       Process in place to       Electronic Solution Healthcare Commission    Evaluation of the          Systematic             L=3    JR
Standards including      achieve sufficient assurance that            C=5       monitor evidence          requires further    Steering Group           evidence base              evaluation to be       C=5
Healthcare               all standards are being achieved.            RR=15     through Healthcare        development across Reports to PCT Board      unsystematic across the    developed.              RR=15
Commission                                                            RED       Commission Steering       the organisation                             organisation               Electronic solutions     RED
development                                      Risk                           Group. Director                                                                                   to be explored further
standards                Register 233                                           Responsibility for each
                                                                                standard identified.


    STRATEGIC OBJECTIVES                                    3. TO ENSURE EFFECTIVE GOVERNANCE AND LEADERSHIP TO DELIVER PCT PURPOSE




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            MASTER                                             RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK - Updated 8/11/2007                                                              APPENDIX 'B'




Objective              Risk                              Mapped Initial      Current Control         Gaps in Control     Current Assurance       Gaps in Assurance    Action Required        Residual   Lead
                                                         to HCC   Risk                                                                                                                       Risk       Director
                                                         Standard Rating                                                                                                                        (C x    Review
                                                         s          (C x L =                                                                                                                 L = )      Date
                                                                  )
3A Finance -           Funds are used to finance the     C7d       C=4       Medium term financial   None                Board to approve the   None                  Set up a financial     C=4        CS
Statutory duties       PCT objectives beyond what is               L=4       plan                                        medium term financial                        investement control        L=     MAR 08
      ALE              affordable recurrently.                     RR = 16                                               plan.                                        process wherby all     3
                       Risk Register 234                           RED                                                   ALE Assessment 06/07 -                       Directors, PE and       RR =
                                                                                                                          Level 3 Good                                Board investement      12
                                                                                                                                                                      proposals are          RED
                                                                                                                                                                      signed off by the
                                                                                                                                                                      finance department




3A Finance -           Expenditure is incurred without   C7d       C=4       Directors and PE review Business planning    Monitoring of new      None                 Development of a       C=4        CS
Statutory duties       reference to value for money.               L=4       of business plans.      template required to developments through                        business planning          L=     MAR 08
      ALE              Risk Register 235                           RR = 16                           cover VFM            FACT                                        template.              2
                                                                   RED                                                        ALE - level 3                                                   RR = 8

                                                                                                                                                                                             AMBER

3A Finance -           Commissioning decisions are       C7d       C=4       Directors and PE review Business planning    Monitoring of new      None                 Development of a       C=4     CS
Statutory duties       based on poor financial and                 L=4       of business plans.      template required to developments through                        business planning        L = 2 MAR 08
      ALE              activity data.                              RR = 16                           cover VFM            FACT                                        template.
                       Risk Register 236                           RED                                                        ALE - level 3                                                  RR = 8

                                                                                                                                                                                             AMBER
3A Finance -           Financial skills at Board,        C7d       C=3       PDR sysytem of          None                L&D department          None                 Use Y&H Finance        C=3        CS
Statutory duties       management and finance                      L=3       indentifying training                       monitoring.                                  Staff Development       L=2       MAR 08
      ALE              department levels are                       RR = 9    needs.                                                                                   system to best effect.    RR
                       inadequate.                                 AMBER                                                                                                                     =6
                       Risk Register237
                                                                                                                                                                                             YELLOW

3B Legal - To comply Reduction in funding will mean              0 L=4       PAG to demonstrate                        0 Regular reporting to                        0 Governance            L=3     JR Dec 08
with all legal       PCT has to take more risks in                 C=4       due process                                 Board and non-exec                            arrangements need     C=5
requirements         cost per case decisions.                      RR=16                                                 Chairing of Appeals                           to be clarified       RR=16
                                    Risk Register 238              RED                                                                                                                           L=3

                                                                                                                                                                                             C=4
                                                                                                                                                                                             RR=12




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            MASTER                                           RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK - Updated 8/11/2007                                                                         APPENDIX 'B'




Objective               Risk                            Mapped Initial      Current Control              Gaps in Control     Current Assurance       Gaps in Assurance           Action Required      Residual   Lead
                                                        to HCC   Risk                                                                                                                                 Risk       Director
                                                        Standard Rating                                                                                                                                  (C x    Review
                                                        s          (C x L =                                                                                                                           L = )      Date
                                                                 )
3B Legal - To comply High profile lapse in Child                0 L=4       1) Safeguarding policies                       0 Reports to Children's   1) Governance               1) Governance        L=5        JR Dec 08
with all legal       Protection leading to a child                C=4       and procedures                                   Board and PCT Board     arrangements could be       arrangements need    C=4
requirements         suffering harm.                              RR=16                 2)                                                           confused during             to be clarified      RR=20
                                Risk Register 239                 RED       Safeguarding Board                                                       Integration of Children's     2) Serious Case     RED
                                                                                       3) Training                                                   Services                    Reviews to be
                                                                            requirement for all                                                             2) Serious Case      reviewed by CGC
                                                                            clinical and non clinical                                                Reviews to be reported
                                                                            staff agreed                                                             to Clinical Governance
                                                                                                                                                     Committee (CGC)



3B Legal - To comply Risk of discrimination, Equality           0 C=4       Disability, Race &           None                Equality Impact         None                        None                 C=3        PF
with all legal       and Human Rights for                           L=3     Gender Equality                                  Assessment on all                                                        L=3
requirements         employment breaches.                            RR =   Schemes & policies &                             employment policies.                                                     RR = 9
                          Risk Register 240                       12 RED    procedures. 6 monthly                            Annual Staff Surveys.                                                    AMBER
                                                                            monitoring reports.                              Key targets report to
                                                                            Equality and Diversity                           Board and E & D 2
                                                                            Website. Equality and                            yearly reports. HCC
                                                                            Diversity in                                     local assessment in
                                                                            Employment. Strategy                             summer, 07
                                                                            and Action Plan.
                                                                            Mandatory Equality and
                                                                            Diversity training for all
                                                                            staff




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            MASTER                                           RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK - Updated 8/11/2007                                                                    APPENDIX 'B'




Objective               Risk                            Mapped Initial      Current Control           Gaps in Control     Current Assurance           Gaps in Assurance       Action Required    Residual   Lead
                                                        to HCC   Risk                                                                                                                            Risk       Director
                                                        Standard Rating                                                                                                                             (C x    Review
                                                        s          (C x L =                                                                                                                      L = )      Date
                                                                 )
3B Legal - To comply Patients, staff and visitors are   C1a, C1b, C = 4     Risk Management                             0 ¼ly Reports to CRM                              0                     0 C=3       PF
with all legal       harmed as a result of              C4b, C7a, L = 3     Framework. Assurance                          and 6 monthly to Board.                                                 L=2       November
requirements         inappropriate action.              C7c, C8a    RR =    Strategy. CRM                                 Accredited to level 1b of                                                RR = 6   2007
                          Risk Register 241                       12 RED    Committee.                                    NHSLA RM standards
                                                                            Incidents/SUIs                                for PCT's, Feb 07.                                                     AMBER
                                                                            complaints / PALS /                                Staff survey.
                                                                            SABS. Health & Safety                         NPSA monitoring of
                                                                            Policy. Risk                                  patient safety incidents.
                                                                            Assessments. RM                                 Healthcare
                                                                            Team. PCT Risk                                Commission standards.
                                                                            Register and Assurance                        Internal Audit.
                                                                            Framework - Analysis of
                                                                            Risk. RM Training / H &
                                                                            S Training. Identifying
                                                                            learning and improving
                                                                            from
                                                                            incidents/complaints
                                                                            reporting. Acting on
                                                                            Safety Alert Bulletins
                                                                            and monitoring same




3B Legal - To comply Supplementary time/resources               0 C=3      Employment Policies & None                     HCC Assessment              None                    None               C=3       PF
with all legal       spent on ER cases and loss of                       L Procedures. Training                           (Summer 2007).                                                               L = Mar 08
requirements         reputation.                                  =4       programmes for                                 RMS Audit Reports .                                                    3
                                 Risk Register 242                     RR Managers. Regular                               Quarterly key target                                                    RR = 9
                                                                  = 12     review of cases,                               reports to the Board.
                                                                  AMBER    procedures and training.                                                                                              AMBER
                                                                            HR prof qualified staff
                                                                           ongoing advice.
                                                                           Management guidance.




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            MASTER                                              RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK - Updated 8/11/2007                                                                             APPENDIX 'B'




Objective              Risk                                Mapped Initial      Current Control          Gaps in Control         Current Assurance        Gaps in Assurance          Action Required          Residual   Lead
                                                           to HCC   Risk                                                                                                                                     Risk       Director
                                                           Standard Rating                                                                                                                                      (C x    Review
                                                           s          (C x L =                                                                                                                               L = )      Date
                                                                    )
3C Estates - To        Current and future premises                 0 C=4       Estates Strategy in      PCT must ensure         Reports to board on      Assurance that             RFT colleagues           C=3        PF
provide fitness for    inappropriately maintained and                 L=3      place.                   RFT involvement         Estates Strategy, Care   operational FM provision   invited on all new       L=3        Dec2007
purpose premises       managed impacting upon service                  RR=12   Premises maintained to   with new projects to    premises, strategic      meets all PCT (NHS)        project groups. New      RR=9
                       provision and staff.                              Red   National & NHS           ensure full portfolio   projects and Estate      requirements and           model FM                 Amber
                         Risk Register 243                                     standards (HTMs, HBNs    coverage.               Performance including    standards where there is   agreement
                                                                               etc).    Estates SLA     Third party FM          a reduction of backlog   third party development    developed and
                                                                               provides minimum         providers may not       maintenance.             or partnership             being piloted at
                                                                               quality & performance    be familiar with                                 development e.g. with      Breathing Space.
                                                                               standards.               Healthcare                                       RMBC.
                                                                               Performance              standards required.
                                                                               Management of SLA via
                                                                               H of E&Facilities


3D Workforce to        Unhealthy staff at work resulting           0 C=3      Health and well being     None                    Key target reports to the Sickness Absence          Robust practical         C=3     PF From
ensure fitness for     in absence from work affecting                      L  action plan in place.                             Board and PE.             Rates above average.      step by step               L = 3 October
purpose                the ability to provide services               =4       Family Friendly policies.                         Financial Information                               guidance for                RR = 2007
                       efficiently and safely. Risk                   RR = 12 Counselling Services.                             Management System                                   consistent               9
                       Register 244                                    AMBER Occupational Health                                (FIMS) reporting across                             application of           AMBER
                                                                              service and Wellbeing                             St HA                                               policies, in addition
                                                                              activities. Sickness                                                                                  to the current
                                                                              Absence monitoring and                                                                                training programme
                                                                              Policy and Procedure.                                                                                 accessible to
                                                                              Management training                                                                                   Managers.
                                                                              Programme.




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            MASTER                                               RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK - Updated 8/11/2007                                                                          APPENDIX 'B'




Objective              Risk                                 Mapped Initial      Current Control           Gaps in Control       Current Assurance       Gaps in Assurance           Action Required        Residual   Lead
                                                            to HCC   Risk                                                                                                                                  Risk       Director
                                                            Standard Rating                                                                                                                                   (C x    Review
                                                            s          (C x L =                                                                                                                            L = )      Date
                                                                     )
3D Workforce to        Patient safety and service quality   C7e,      C=3       Statutory/mandatory       Not all staff         Annual review of dept.   Not all managers using     Continuing             C=3        PF
ensure fitness for     is compromised as a result of        C11a,       L=4     training/learning         receiving all         L&D plans. Monitoring MY PORTAL to monitor          introduction of         L=3       March
purpose                non-provision or lack of uptake      C11b,        RR =   programmes for all        mandatory learning    & reporting of staff     attendance.                blended learning to    RR = 9     2008
                       of training/learning essential to    C11c      12 RED    clinical & non-clinical   / training. Not all   uptake of                                           rationalise            AMBER      Directors/C
                       role(s).                                                 staff. Access to          managers using        statutory/mandatory                                 mandatory training                E
                       Risk Register 245                                        Learning policy in        dept reporting        training/learning.                                  to practicable levels             Dec 2007
                                                                                operation. Annual         facility via MY       Attendance recorded                                 by L&D dept - March
                                                                                PDR/PDP. Quality          PORTAL.               via MY PORTAL.                                      08. Monitoring &
                                                                                assurance of                                    Twice yearly report on                              remedial action by
                                                                                training/learning                               uptake of                                           dept managers to
                                                                                packages via subject-                           statutory/mandatory                                 ensure staff attend
                                                                                specialists. Quality                            training/learning to PCT                            mandatory
                                                                                assurance of KSF                                Risk Management                                     training/learning
                                                                                Outlines & Gateway                              Committee.                                          activities, inc use of
                                                                                reviews. Record of                              Staff surveys.                                      MY PORTAL by
                                                                                attendance via MY                                                                                   December 07.
                                                                                PORTAL.

3E Information / IT /  Board do not receive systematic              0 L=5       Extensive analysis        Lack of prioritisation Ad hoc reporting to                              0 Strategic              L=2        AB
Intelligence      To   intelligence required to make                  C=3       already taking place      in reports that        Board                                              Intelligence Review    C=3        Mar 08
ensure timely relevant effective decisions.                           RR=15                               Board receives                                                            from November 07        RR=6
and accurate                    Risk Register 246                     RED                                                                                                                                   Yellow
reporting to inform
decision making.
Deliver Connecting
for Health (inc NLOP
responsibilities)


3F Partnership -       Partnership arrangements are                 0 L=3       Lead provider             Only Ad hoc reports                          0 Assurance process is       Need formal           C=4         KA
Maintain and develop not explicit and monitored                         C=4     arrangements.             to Board at the                                not yet systematic.        process for reporting             Mar 08
good partnership       against target.                                  RR=12   Joint Boards.             moment.                                                                   to Board.             L=2
working with principle           Risk Register 247                        RED   Joint commissioning
providers / LA / SHA /                                                          arrangements.                                                                                                              RR=8
Voluntary Sector /                                                              Joint policies &
External Agencies                                                               procedures.                                                                                                                AMBER




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            MASTER                                          RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK - Updated 8/11/2007                                                              APPENDIX 'B'




Objective              Risk                            Mapped Initial      Current Control            Gaps in Control     Current Assurance        Gaps in Assurance   Action Required    Residual   Lead
                                                       to HCC   Risk                                                                                                                      Risk       Director
                                                       Standard Rating                                                                                                                       (C x    Review
                                                       s          (C x L =                                                                                                                L = )      Date
                                                                )
3G To ensure that      Services not being responsive to C16, C17, C = 4      PPE Sub group. PPE      Lack of quality in   6 monthly report to                          Implementation of      C=3    PF/SMH
services               local need and what people       D8 and          L=   Strategy & action plan. indicators in        Board. Non Executive                         PPE action plan.       L=3     JR/CS
commissioned and       want.                            D11a      3          Links with Overview and contracts            Committee for PPE.                                     Inclusion of RR = 9 March 08
provided are                             Risk Register            RR = 12    Scrutiny. PPE Toolkit.                       Feedback from O+S.                           quality indicators in   AMBER
responsive to          248                                         RED       Joint LA/PCT.                                Healthcare Commission                        contacts.
patient's needs and                                                          Consultation protocol.                       assessment . Patient
wishes.                                                                      Monitoring of PALS and                       survey satisfaction -
                                                                             complaints / compliment                      Access survey to board
                                                                             information                                  September 07.




    STRATEGIC OBJECTIVE                               4. TO IMPROVE HEALTH SERVICES ACROSS ROTHERHAM VIA OWN PROVIDER FUNCTION
Cross reference to 3
where appropriate




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            MASTER                                             RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK - Updated 8/11/2007                                                                         APPENDIX 'B'




Objective               Risk                              Mapped Initial      Current Control            Gaps in Control        Current Assurance         Gaps in Assurance      Action Required        Residual   Lead
                                                          to HCC   Risk                                                                                                                                 Risk       Director
                                                          Standard Rating                                                                                                                                  (C x    Review
                                                          s          (C x L =                                                                                                                           L = )      Date
                                                                   )
4A To achieve 'arms     Governance arrangements do                0 L=3         (1)Trust (Provider)                         0 (1)Separate Trust Board (1)Review of arms          (1)Option appraisal    L=2        To be
length arrangements'    not achieve 'arms length                                Board meets once every                        agenda for Provider and length arrangement and     for model of                      completed
for Provider Services   arrangements' for Provider                  C=3         2 months with separate                        Commissioning mode.     appraisal of model of      provision for          C=2        by March
with PCT                Services.                                               Trust Board agenda                                                    provision                  Rotherham PCT                     2008
                                     Risk Register 249              RR=9        (From commissioning                                                   (2)Progress against        Provider Services      RR=4       KH
                                                                    AMBER       agenda).                                                              Business Plan not                  (2)Action
                                                                                        (2) Core                                                      monitored                  Plan and monitoring    GREEN
                                                                                Management Team                                                                                  at CMT meetings
                                                                                established which is                             (2)Buisness Plan                                and reports to
                                                                                responsible for all                             agreed at PCT Provider                           Provider Services                 Dec 07
                                                                                functions within the                            Board.                                                                             KH
                                                                                Directorate                                              (3)Core
                                                                                                                                Management Team
                                                                                                                                Terms of Reference
                                                                                                                                agreed by Trust Board
                                                                                                                                and meetings held
                                                                                                                                monthly.
                                                                                                                                             (4)HCC
                                                                                                                                compliance against
                                                                                                                                standards monitored for
                                                                                                                                Provider Services as
                                                                                                                                part of PCT
                                                                                                                                Performance process.

                                                                                                                                    (5)StHA Monitoring.




4B Successful           Directorate does not meet the             0 L=3         Monthly meetings with    Need to operate in     Terms of Reference of                          0 Minutes from           L=2        KH
performance against     requirements of the 2007/08                       C=3   contracting team         operational/           both types of                                    meetings to go to                 Mar 08
2007/08 Service Level   Service Level Agreement.                                                         strategic mode at      contracting meetings                             Provider CMT           C=3
Agreement with PCT                    Risk Register 250             RR=9                                 every other meeting.   reviewed                                         monthly Business
Commissioners                                                         AMBER                                                                                                      mtg as part of         RR=6
                                                                                                                                                                                 performance
                                                                                                                                                                                 monitoring             YELLOW




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            MASTER                                                     RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK - Updated 8/11/2007                                                                                APPENDIX 'B'




Objective                   Risk                                  Mapped Initial      Current Control            Gaps in Control        Current Assurance         Gaps in Assurance          Action Required           Residual   Lead
                                                                  to HCC   Risk                                                                                                                                        Risk       Director
                                                                  Standard Rating                                                                                                                                         (C x    Review
                                                                  s          (C x L =                                                                                                                                  L = )      Date
                                                                           )
                        0                                     0           0            0 Performance against                          0 (1)reports and minutes  No integrated                Balanced' score                    0 Jan 08 KH
                                                                                         contract monitored by                          from Core Management performance report              card approach to be
                                                                                         Head of Business unit                          Team meetings.         combining activity and        incorporated in
                                                                                         and Core Management                                 (2)Report to      quality                       reporting to CMT
                                                                                         Team(CMT).                                     Provider Board                                       and Provider Board


                                                                                        Performance against                             Reports to CMT and to     CRES not fully identified Plan to achieve                     0 End of
                                                                                        Budget monitored by                             Provider Board            or achieved               CRES required                         Nov 2007
                                                                                        CMT, Senior Managers                                                                                                                      KH
                                                                                        and Heads of Dept


4C Implementation of        Impact upon service continuity        C9          L=4       (1) Project Board in                          0 (1) Meetings held and     (3) Review not yet         (3) Review to be          L=3       KH
System One/TPP              during implementation of a new                       C=4    Place                                           minutes recorded      .   completed                  completed                       C=3 Mar 08
connecting for Health       community connecting for health                             (2) Project Initiation                          Project Plan
compliant IT system         compliant IT system.                              RR=16     Document (Community                             (Implementation) in                                                            RR=9
                            Risk Register 251                                    RED    and Child Health) plan                          place and in progress.
                                                                                        in place                                                  (2)System                                                            AMBER
                                                                                                                                        data and quality
                                                                                                                                        monitored
                                                                                                                                        (3) 6/12 monthly review
                                                                                                                                        of records planned


                                                                                                                                        Risk Register reviewed    Concern of impact upon     Implementation plan                0 Dec 07 KH
                                                                                                                                        by Project Board          frontline staff capacity   'tailored' to relevant
                                                                                                                                                                                             department.
                                                                                                                                                                                             Pilot in use of
                                                                                                                                                                                             mobile technology


                                                                                                                                                                  Final templates and        Documentation                        Mar 08
                                                                                                                                                                  paperlight system          templates to be                       KH
                                                                                                                                                                  require approval by        finalised and
                                                                                                                                                                  appropriate governance     approved
                                                                                                                                                                  mechanism


                                                                                                                 Maintained plan                                  System maintenance/        Plan to be                           Dec 07 KH
                                                                                                                 (following                                       plan continuity required   developed for one
                                                                                                                 implementation) to                                                          implementation
                                                                                                                 be in place                                                                 complete




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            MASTER                                              RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK - Updated 8/11/2007                                                                                    APPENDIX 'B'




Objective               Risk                               Mapped Initial      Current Control              Gaps in Control         Current Assurance          Gaps in Assurance           Action Required          Residual    Lead
                                                           to HCC   Risk                                                                                                                                            Risk        Director
                                                           Standard Rating                                                                                                                                             (C x     Review
                                                           s          (C x L =                                                                                                                                      L = )       Date
                                                                    )
4D to ensure clinical   Directorate fails to meet Health   Hygiene  L=5          (1)Infection Control                             0 (1)Minutes received by     (1)Breathing Space now      (1)Review against        L=3       Dec-07
quality and patients    Act compliance and new             Code         C=4      Committee                                          clinical governance        operational and             Infection Control              C=4 KH
safety in accordance    Decontamination requirements.      duties                       (2)Director for                             committee                  assessment against          requirements
with Healthcare         Risk Register 252                  1=11 C4C RR=20        Infection Prevention and                                   (2)Annual Report   standards to be             (2)Implement             RR=12
Commission                                                 C21 C4a    RED        Control                                            to Trust board             completed. Regular          recommendations.            RED
Standards                                                                        (3)Infection Control                                          (3) NHSLA       review in light of
                                                                                 Control Team                                       Level 1 achieved           increasing patient          (3)Regular
                                                                                       (4)Mandatory                                                            activity                    monitoring and audit
                                                                                 Infection Control                                  (4)Evidence against                        (2)Review   of in patient areas
                                                                                 Training and Updates                               HCC standards              requirement against         including Breathing
                                                                                                                                        (5)DIPC attends        Health Act requirements     Space
                                                                                 (5)Handwashing/                                    Trust Board + job desc.    to ensure all procedures           (4)Procedures
                                                                                 Infection Control                                                    (5)      and systems in place are    to be approved and
                                                                                                                                    Infection Control          up to date                  implemented
                                                                                                                                    Policies and Procedures




                                                                                 Plan for Risk              All services do not     (1)Single use            Declaration of lapse and      Trust Board to be                 0 Mar-08
                                                                                 minimisation within        comply with new         instruments and CSSD action plan                       updated re current                  KH
                                                                                 services agreed at Trust   Decontamination         used whenever                                          lapse.
                                                                                 Board                      standards               possible.                                              Tendering process
                                                                                                                                    (2)Risk areas minimised                                and new contract to
                                                                                                                                    as far as possible until                               be in place by
                                                                                                                                    tender of revised                                      March 08
                                                                                                                                    service completed.


4D to ensure clinical   Children may be harmed due to      C9        L=3         (1)Professional record     (1)Not possible to      (1)Provider Board        (1)achievement of action      (1)Investigation root    L=3         Apr-08 KH
quality and patients    unavailable/missing clinical                       C=4   keeping standards          track all record        informed of significant  plan                          cause analysis and             C=3
safety in accordance    records of children.                                        (2) Clinical Records    movements               lapse, root cause                                      action plan to be
with Healthcare                Risk Register 253                     RR=12       Committee                                          analysis and action plan                               completed/                RR=9
Commission                                                            RED        (3)Medical Records                                 developed to address                                   achieved.
Standards                                                                        Policy                                             lapse                                                  (2)Improve records       AMBER
                                                                                                                                                                                           management in line
                                                                                                                                                                                           with implementation
                                                                                                                                                                                           of electronic
                                                                                                                                                                                           healthcare record
                                                                                                                                                                                           system (TPP)




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            MASTER                                            RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK - Updated 8/11/2007                                                                          APPENDIX 'B'




Objective               Risk                             Mapped Initial      Current Control            Gaps in Control     Current Assurance        Gaps in Assurance           Action Required        Residual   Lead
                                                         to HCC   Risk                                                                                                                                  Risk       Director
                                                         Standard Rating                                                                                                                                   (C x    Review
                                                         s          (C x L =                                                                                                                            L = )      Date
                                                                  )
4D to ensure clinical   Failure to safeguard children.   C2        L=4       (1)Child Protection                          0 (1)Clinical Governance   (1)Up to date audit of      (1)Audit to be         L=3        Dec 08
quality and patients    Risk Register 254                                    Procedures                                     Development Plan         safeguarding                completed
safety in accordance                                               C=5       (2)Safeguarding Board                          (2)Child Health          arrangements in             (2)Arrangements to     C=5
with Healthcare                                                                                                             Protection Forum         accordance with             be reviewed as part
Commission                                                         RR=20     (3)Designated and                              (3)Agreed training       Children's Act              of Children's Trust    RR=15
Standards                                                                    named Professionals for                        programme                    (2) Outstanding         arrangements                       March 08
                                                                             safeguarding                                   (4)Child protection      actions against part 8                                         KH
                                                                                                                            supervision and local    reviews.
                                                                                                                            standards


4E Integrated           Risk that new arrangements for   C2 all    L=2     PCT Board and                                    Reports to PCT Board     Final proposal /            (1)Final proposal /   L=3    Dec 08
Frontline Service       commissioning/ provision of      domains       C=5 partnership structure                            and Children's Board     business case in relation   Business case to be
delivery as part of     C&YP services do not enable      of HCC            including CEO, Non                                                        to Childrens' Trust         agreed by PCT         C=3    March 08
Children's Trust        PCT to meet 5 key tests:-                  RR=10   Executive and Lead                                                        arrangements.               Board                    RR=9 March
arrangements                             (a) Statutory                     Director                                                                  Commissioning contract                  (2) To           08 KH
                        duties discharge                                   Childrens Board work                                                      PCT/ RMBC required          complete contract
                         (b)Outcomes are improved for                      programme part of PCT                                                                Provision                        (3)To
                        children and young people                          corporate priority                                                        SLA RMBC/PCT                complete SLA
                        (c)new arrangements are safe                       programme                                                                 provider required
                                                (d)Human                   Children and Young
                        resources                                          People's plan.
                        arrangement are robust                             Consultation for frontline
                          (e) Arrangements are                             integration undertaken
                        affordable.                                        and now complete
                                      Risk Register 255




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            KSA                                        RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                          Update 26/10/2007




Objective              Risk                            Mapped Initial      Current Control             Gaps in Control      Current Assurance        Gaps in Assurance         Action Required        Residual   Lead
                                                       to HCC   Risk                                                                                                                                  Risk       Director
                                                       Standard Rating                                                                                                                                   (C x    Review
                                                       s          (C x L =                                                                                                                            L = )      Date
                                                                )
What the organisation What could prevent this          e.g. C1(a)             What controls/           Where we are         Where we can gain        Where we are failing to   What needs to be
aims to deliver       objective being achieved                                systems we have in       failing to put       evidence that our        provide evidence that     carried out to
                      RR=Risk Register                                        place to assist in       controls / systems   controls/ systems, on    our controls /            reduce the risk. By
                                                                              securing delivery of     in place             which we are placing     assessments are           when
                                                                              our objectives.                               reliance are effective   effective


    STRATEGIC OBJECTIVE                                1. TO IMPROVE THE HEALTH AND WELL BEING OF THE ROTHERHAM POPULATION
1A To reduce health
inequalities - 2010
targets short term

1B To reduce health    Inequitable use of funding -                 L=3       Contract compliance      No systematic      Report to LSP                                        Need a systematic                 KA/JR
inequalities in the    manage contracts to target                    C=4      Review of progress       process to measure                                                      process to identify               CS
medium to long term    resources to areas of need.                   RR=12    between areas            compliance by                                                           and compare                       Mar 08
                                                Risk                  RED                              target group area                                                       investment &
                       Register 217                                                                                                                                            outcome between
                                                                                                                                                                               areas and a process
                                                                                                                                                                               for actioning change



1C Safeguarding
Health in Emergency
Planning / Service
Continuity

1D Delivering
Community wide
health regeneration
through working with
external agencies /
sectors


    STRATEGIC OBJECTIVE                                2. TO IMPROVE HEALTH SERVICES ACROSS ROTHERHAM
2A To deliver existing Unplanned care requirements                  L=3       Activity monitoring by   Lack of real time    Activity monitoring      None                      More timely            C=4     KA
and new national       continue to escalate.                          C=4     FACT                     management of        reports to PE & Board                              monitoring of activity     L=2 Mar 08
targets                      Risk Register 227                                                         activity                                                                and cause of
                                                                    RR=12                                                                                                      unplanned activity     RR=8
                                                                    RED                                                                                                                               AMBER




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            KSA                                            RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                      Update 26/10/2007




Objective               Risk                               Mapped Initial      Current Control           Gaps in Control   Current Assurance         Gaps in Assurance   Action Required      Residual   Lead
                                                           to HCC   Risk                                                                                                                      Risk       Director
                                                           Standard Rating                                                                                                                       (C x    Review
                                                           s          (C x L =                                                                                                                L = )      Date
                                                                    )
2A To deliver existing Patient Choice & booking            C18       C=3       Close monitoring of       None              Regular reports to PE &                       Ongoing plan to      C=3        KA
and new national       arrangements not delivered.                   L=4       targets by Choose &                         Board                                         identify further        L=3     Mar 08
targets                   Risk Register 226                          RR=12     Book team                                   National surveys                              action needed
                                                                                                                                                                                              AMBER
                                                                     AMBER


2B To effectively      Financial implications -High cost   C 7a      L=3       1) PAG & Continuing       None              Reports to PE & Board     None                New data base        C=4        KA
commission first       of individual placements            C 18       C=4      Care process in place                       as part of key targets                        being developed in   L=2        MARCH 08
class services for     (continuing care and PAG).          C 19       RR=12                                                                                              Continuing Care.
Primary, Secondary                                         D 11         RED                                                                                                         Further
and Tertiary Services,         Risk Register 231                                                                                                                         training on          RR=8
including out of hours                                                                                                                                                   implementation of
and emergency care                                                                                                                                                       new Continuing       AMBER
e.g. Commissioning                                                                                                                                                       Care criteria
for patient safety.
Quality and patient
experience




2B To effectively      PCT not able to identify            C7a       L=3       Contract monitoring and                     Target report to Board                        Integrated           C=3        KA
commission first       disengage from PC or contracts.      C18      C=4       action required                             monthly                                       management &                      Mar 08
class services for                                           C19     RR=12                                                 Exceptions reporting                          monitoring of         L=2
Primary, Secondary           Risk Register 232                D11      RED                                                                                               contracts
and Tertiary Services,
including out of hours                                                                                                                                                                        YELLOW
and emergency care
e.g. Commissioning
for patient safety.
Quality and patient
experience




2 C To meet National
Standards including
Healthcare
Commission
development
standards




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            KSA                                        RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                      Update 26/10/2007




Objective                Risk                          Mapped Initial      Current Control          Gaps in Control       Current Assurance   Gaps in Assurance      Action Required      Residual   Lead
                                                       to HCC   Risk                                                                                                                      Risk       Director
                                                       Standard Rating                                                                                                                       (C x    Review
                                                       s          (C x L =                                                                                                                L = )      Date
                                                                )

    STRATEGIC OBJECTIVES                              3. TO ENSURE EFFECTIVE GOVERNANCE AND LEADERSHIP TO DELIVER PCT PURPOSE
3A Finance -
Statutory duties
       ALE
3B Legal - To comply
with all legal
requirements
3C Estates - To
provide fitness for
purpose premises
3D Workforce
3E Information / IT /
Intelligence      To
ensure timely relevant
and accurate
reporting to inform
decision making.
Deliver Connecting
for Health (inc NLOP
responsibilities)


3F Partnership -       Partnership arrangements are              L=3          Lead provider         Only Ad hoc reports                       Assurance process is   Need formal           C=4       KA
Maintain and develop not explicit and monitored                   C=4         arrangements.         to Board at the                           not yet systematic.    process for reporting           Mar 08
good partnership       against target.                            RR=12       Joint Boards.         moment.                                                          to Board.             L=2
working with principle           Risk Register 247                   RED      Joint commissioning
providers / LA / SHA /                                                        arrangements.                                                                                               RR=8
Voluntary Sector /                                                            Joint policies &
External Agencies                                                             procedures.                                                                                                 AMBER




3G Public / Patient
Engagement / Patient
Experience
    STRATEGIC OBJECTIVE                               4. TO IMPROVE HEALTH SERVICES ACROSS ROTHERHAM VIA OWN PROVIDER FUNCTION
Cross reference to 3
where appropriate




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            AB                                         RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                        Updated ________




Objective                Risk                          Mapped Initial      Current Control           Gaps in Control      Current Assurance        Gaps in Assurance         Action Required       Residual   Lead
                                                       to HCC   Risk                                                                                                                               Risk       Director
                                                       Standard Rating                                                                                                                                (C x    Review
                                                       s          (C x L =                                                                                                                         L = )      Date
                                                                )
What the organisation What could prevent this          e.g. C1(a)             What controls/         Where we are         Where we can gain        Where we are failing to   What needs to be
aims to deliver       objective being achieved                                systems we have in     failing to put       evidence that our        provide evidence that     carried out to
                      RR=Risk Register                                        place to assist in     controls / systems   controls/ systems, on    our controls /            reduce the risk. By
                                                                              securing delivery of   in place             which we are placing     assessments are           when
                                                                              our objectives.                             reliance are effective   effective


    STRATEGIC OBJECTIVE                               1. TO IMPROVE THE HEALTH AND WELL BEING OF THE ROTHERHAM POPULATION
1A To reduce health
inequalities - 2010
targets short term

1B To reduce health
inequalities in the
medium to long term

1C Safeguarding
Health in Emergency
Planning / Service
Continuity

1D Delivering
Community wide
health regeneration
through working with
external agencies /
sectors


    STRATEGIC OBJECTIVE                               2. TO IMPROVE HEALTH SERVICES ACROSS ROTHERHAM
2A To deliver existing
and new national
targets




            D:\Docstoc\Working\pdf\ce227177-d511-40fd-9275-06d03c6f7b33.xls
            AB                                         RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                           Updated ________




Objective                Risk                          Mapped Initial      Current Control   Gaps in Control   Current Assurance   Gaps in Assurance   Action Required   Residual   Lead
                                                       to HCC   Risk                                                                                                     Risk       Director
                                                       Standard Rating                                                                                                      (C x    Review
                                                       s          (C x L =                                                                                               L = )      Date
                                                                )
2B To effectively
commission first
class services for
Primary, Secondary
and Tertiary Services,
including out of hours
and emergency care
e.g. Commissioning
for patient safety.
Quality and patient
experience




2 C To meet National
Standards including
Healthcare
Commission
development
standards


    STRATEGIC OBJECTIVES                              3. TO ENSURE EFFECTIVE GOVERNANCE AND LEADERSHIP TO DELIVER PCT PURPOSE
3A Finance -
Statutory duties
       ALE
3B Legal - To comply
with all legal
requirements
3C Estates - To
provide fitness for
purpose premises
3D Workforce




            D:\Docstoc\Working\pdf\ce227177-d511-40fd-9275-06d03c6f7b33.xls
            AB                                         RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                           Updated ________




Objective                Risk                          Mapped Initial      Current Control   Gaps in Control   Current Assurance   Gaps in Assurance   Action Required   Residual   Lead
                                                       to HCC   Risk                                                                                                     Risk       Director
                                                       Standard Rating                                                                                                      (C x    Review
                                                       s          (C x L =                                                                                               L = )      Date
                                                                )
3E Information / IT /
Intelligence      To
ensure timely relevant
and accurate
reporting to inform
decision making.
Deliver Connecting
for Health (inc NLOP
responsibilities)


3F Partnership -
Maintain and develop
good partnership
working with principle
providers / LA / SHA /
Voluntary Sector /
External Agencies




3G Public / Patient
Engagement / Patient
Experience
    STRATEGIC OBJECTIVE                               4. TO IMPROVE HEALTH SERVICES ACROSS ROTHERHAM VIA OWN PROVIDER FUNCTION
Cross reference to 3
where appropriate




            D:\Docstoc\Working\pdf\ce227177-d511-40fd-9275-06d03c6f7b33.xls
            PF                                         RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                       Updated 26/10/2007




Objective                Risk                          Mapped Initial      Current Control           Gaps in Control      Current Assurance        Gaps in Assurance         Action Required       Residual   Lead
                                                       to HCC   Risk                                                                                                                               Risk       Director
                                                       Standard Rating                                                                                                                                (C x    Review
                                                       s          (C x L =                                                                                                                         L = )      Date
                                                                )
What the organisation What could prevent this          e.g. C1(a)             What controls/         Where we are         Where we can gain        Where we are failing to   What needs to be
aims to deliver       objective being achieved                                systems we have in     failing to put       evidence that our        provide evidence that     carried out to
                      RR=Risk Register                                        place to assist in     controls / systems   controls/ systems, on    our controls /            reduce the risk. By
                                                                              securing delivery of   in place             which we are placing     assessments are           when
                                                                              our objectives.                             reliance are effective   effective


    STRATEGIC OBJECTIVE                               1. TO IMPROVE THE HEALTH AND WELL BEING OF THE ROTHERHAM POPULATION
1A To reduce health
inequalities - 2010
targets short term

1B To reduce health
inequalities in the
medium to long term

1C Safeguarding
Health in Emergency
Planning / Service
Continuity

1D Delivering
Community wide
health regeneration
through working with
external agencies /
sectors


    STRATEGIC OBJECTIVE                               2. TO IMPROVE HEALTH SERVICES ACROSS ROTHERHAM
2A To deliver existing
and new national
targets




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            PF                                          RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                      Updated 26/10/2007




Objective                Risk                           Mapped Initial      Current Control            Gaps in Control     Current Assurance      Gaps in Assurance   Action Required   Residual   Lead
                                                        to HCC   Risk                                                                                                                   Risk       Director
                                                        Standard Rating                                                                                                                    (C x    Review
                                                        s          (C x L =                                                                                                             L = )      Date
                                                                 )
2B To effectively
commission first
class services for
Primary, Secondary
and Tertiary Services,
including out of hours
and emergency care
e.g. Commissioning
for patient safety.
Quality and patient
experience




2 C To meet National
Standards including
Healthcare
Commission
development
standards


    STRATEGIC OBJECTIVES                                3. TO ENSURE EFFECTIVE GOVERNANCE AND LEADERSHIP TO DELIVER PCT PURPOSE
3A Finance -
Statutory duties
       ALE
3B Legal - To comply Legal action being taken against   C4 a-e    C=4         Risk Management          Documented Risk     Corporate Risk          None               Departments /       C=2     PF
with all legal       the PCT relating to Health &       C7c        L=2        Framework in place.      Assessment is not   Management and                             services to ensure      L=4 Dec 2007
requirements         Safety non Compliance              C20a      RR=8        Risk Assurance           consistent across   Clinical Governance                        documented risk
                                                        D1        AMBER       Framework (Risk          all departments /   Committees.     Reports                    assessment in place RR=4
                                                        D12                   Register) in place.      services            to Board e.g. Key
                                                                              H&S policy and                               Targets.                                                     Green
                                                                              supporting procedures
                                                                              and guidance in place.
                                                                              Risk assessment
                                                                              process undertaken H &
                                                                              SC.




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            PF                                          RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                           Updated 26/10/2007




Objective               Risk                            Mapped Initial      Current Control                Gaps in Control   Current Assurance       Gaps in Assurance   Action Required   Residual   Lead
                                                        to HCC   Risk                                                                                                                      Risk       Director
                                                        Standard Rating                                                                                                                       (C x    Review
                                                        s          (C x L =                                                                                                                L = )      Date
                                                                 )
3B Legal - To comply Supplementary time/resources                 C=3      Employment Policies & None                        HCC Assessment          None                None              C=3       PF
with all legal       spent on ER cases and loss of                       L Procedures. Training                              (Summer 2007).                                                      L = Mar 08
requirements         reputation.                                  =4       programmes for                                    RMS Audit Reports .                                           3
                                 Risk Register 242                     RR Managers. Regular                                  Quarterly key target                                           RR = 9
                                                                  = 12     review of cases,                                  reports to the Board.
                                                                  AMBER    procedures and training.                                                                                        AMBER
                                                                            HR prof qualified staff
                                                                           ongoing advice.
                                                                           Management guidance.



3B Legal - To comply Risk of discrimination, Equality             C=4         Disability, Race &           None              Equality Impact         None                None              C=3        PF
with all legal       and Human Rights for                           L=3       Gender Equality                                Assessment on all                                             L=3        Mar 08
requirements         employment breaches.                            RR =     Schemes & policies &                           employment policies.                                          RR = 9
                          Risk Register 240                       12 RED      procedures. 6 monthly                          Annual Staff Surveys.                                         AMBER
                                                                              monitoring reports.                            Key targets report to
                                                                              Equality and Diversity                         Board and E & D 2
                                                                              Website. Equality and                          yearly reports. HCC
                                                                              Diversity in                                   local assessment in
                                                                              Employment. Strategy                           summer, 07
                                                                              and Action Plan.
                                                                              Mandatory Equality and
                                                                              Diversity training for all
                                                                              staff




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            PF                                          RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                        Updated 26/10/2007




Objective               Risk                            Mapped Initial      Current Control             Gaps in Control   Current Assurance           Gaps in Assurance   Action Required   Residual   Lead
                                                        to HCC   Risk                                                                                                                       Risk       Director
                                                        Standard Rating                                                                                                                        (C x    Review
                                                        s          (C x L =                                                                                                                 L = )      Date
                                                                 )
3B Legal - To comply Patients, staff and visitors are   C1a, C1b, C = 4       Risk Management                             ¼ly Reports to CRM                                                C=3        PF
with all legal       harmed as a result of              C4b, C7a, L = 3       Framework. Assurance                        and 6 monthly to Board.                                           L=2        November
requirements         inappropriate action.              C7c, C8a    RR =      Strategy. CRM                               Accredited to level 1b of                                          RR = 6    2007
                          Risk Register 241                       12 RED      Committee.                                  NHSLA RM standards
                                                                              Incidents/SUIs                              for PCT's, Feb 07.                                                AMBER
                                                                              complaints / PALS /                              Staff survey.
                                                                              SABS. Health & Safety                       NPSA monitoring of
                                                                              Policy. Risk                                patient safety incidents.
                                                                              Assessments. RM                               Healthcare
                                                                              Team. PCT Risk                              Commission standards.
                                                                              Register and Assurance                      Internal Audit.
                                                                              Framework - Analysis of
                                                                              Risk. RM Training / H &
                                                                              S Training. Identifying
                                                                              learning and improving
                                                                              from
                                                                              incidents/complaints
                                                                              reporting. Acting on
                                                                              Safety Alert Bulletins
                                                                              and monitoring same




3B Legal - To comply The PCT has inadequate             c7a, C8a   C = 4      SFI SO Policies                             Assurance Framework -                                             C=3    PF
with all legal       policies and procedures to                    L=2        H&S Policies and Risk                        Analysis of Risk                                                 L-1
requirements         comply with current legislation               RR = 8     Assessment                                  considered by Directors,                                          RR = 3
                     and mitigate risk to the                      AMBER      programme.                                  CRM Committee and                                                 YELLOW
                     organisation.                                            Employment Policies,                        Board. *Internal Audit
                                                                              Operational Policies.                       verification of
                                                                                                                          Assurance Framework.
                                                                                                                                *SHA approved.
                                                                                                                          *Head of Internal Audit
                                                                                                                          opinion. *Statement on
                                                                                                                          Internal Control




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            PF                                          RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                              Updated 26/10/2007




Objective              Risk                             Mapped Initial      Current Control              Gaps in Control         Current Assurance        Gaps in Assurance          Action Required       Residual   Lead
                                                        to HCC   Risk                                                                                                                                      Risk       Director
                                                        Standard Rating                                                                                                                                       (C x    Review
                                                        s          (C x L =                                                                                                                                L = )      Date
                                                                 )
3C Estates - To        Current and future premises                C=4         Estates Strategy in        PCT must ensure         Reports to board on      Assurance that             RFT colleagues        C=3        PF
provide fitness for    inappropriately maintained and              L=3        place.                     RFT involvement         Estates Strategy, Care   operational FM provision   invited on all new    L=3        Dec2007
purpose premises       managed impacting upon service               RR=12     Premises maintained to     with new projects to    premises, strategic      meets all PCT (NHS)        project groups. New   RR=9
                       provision and staff.                           Red     National & NHS             ensure full portfolio   projects and Estate      requirements and           model FM              Amber
                         Risk Register 243                                    standards (HTMs, HBNs      coverage.               Performance including    standards where there is   agreement
                                                                              etc).    Estates SLA       Third party FM          a reduction of backlog   third party development    developed and
                                                                              provides minimum           providers may not       maintenance.             or partnership             being piloted at
                                                                              quality & performance      be familiar with                                 development e.g. with      Breathing Space.
                                                                              standards.                 Healthcare                                       RMBC.
                                                                              Performance                standards required.
                                                                              Management of SLA via
                                                                              H of E&Facilities


                       b) PCT strategy for the                    C=4         Care premises strategy                             Reports to board on                                                       C=3        PF
                       replacement and upgrading of                L=2        supported by legal                                 Estates Strategy, Care                                                      L=2      Dec2007
                       care premises not fulfilled.               RR=8        agreements with private                            premises, strategic                                                         RR=6
                                                                  Amber       and public partners for                            projects
                                                                              the provision of new                                                                                                         Yellow
                                                                              premises


                       c) Unhygienic environment for              C=4         Staff training including   More monitoring         PEAT scores published                               Introduce electronic C=3        PF
                       patients and staff.                         L=2        Infection Control.         required.               and CE notified.                                    monitoring systems       L=2    Dec2007
                                                                  RR=8        Regular supervision and    Specification review    Complaint monitoring.                               to increase              RR=6
                                                                   Amber      monitoring. Regular        and update              ERIC returns. Annual                                supervisor capacity      Yellow
                                                                              meetings with Service                              Estates Performance                                 and increase
                                                                              Heads. PEAT                                        report to the Board                                 availability of reports.
                                                                              inspections. Food
                                                                              preparation kitchens
                                                                              registered with EH.
                                                                              Infection Control Nurses
                                                                              and systems.




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            PF                                           RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                           Updated 26/10/2007




Objective              Risk                              Mapped Initial      Current Control             Gaps in Control       Current Assurance          Gaps in Assurance         Action Required         Residual   Lead
                                                         to HCC   Risk                                                                                                                                      Risk       Director
                                                         Standard Rating                                                                                                                                       (C x    Review
                                                         s          (C x L =                                                                                                                                L = )      Date
                                                                  )
                       d) Food quality diminishes.                 C=2        Staff training including   Monitoring of third   PEAT scores published      Performance indicators    Introduce PI's,         C=2        PF
                                                                   L=3        Hygiene Standards and      party providers       and CE notified.           to be developed for       satisfaction surveys     L=2       Dec2007
                                                                   RR=6       Nutrition. Supervision     required. Patient     Complaint monitoring.      provision both in house   more frequent           RR=4
                                                                   Yellow     and monitoring against     survey and            ERIC returns.              and external providers.   monitoring              Green
                                                                              'Better Food in            feedback.             Environmental Health
                                                                              Hospitals' standards                             inspections and reports.
                                                                              and client needs.                                Incident reports.
                                                                              Purchasing policies.
                                                                              PEAT inspections. Food
                                                                              preparation kitchens
                                                                              registered with EH.




3D Workforce to        Inadequate staff information                C=3     ESR Project Plan Risk         None                  ESR Project Board and      None                      Project Board and       C=2     PF March
ensure fitness for     system impacting on PCT                      L=4    and issue log. Benefits                             St HA. Readiness                                     stakeholder              L=2    2008
purpose                performance                                  RR = 9 realisation Plan                                    Assessments                                          approval of detailed       RR =
                                                                   AMBER                                                       Monitoring of BRP                                    benefits realisation    4
                                                                                                                                                                                    plan. Resources         GREEN
                                                                                                                                                                                    required to be
                                                                                                                                                                                    planned to achieve
                                                                                                                                                                                    objectives of plan.



3D Workforce Fitness Unhealthy staff at work resulting             C=3      Health and well being     None                     Key target reports to the Sickness Absence           Robust practical        C=3     PF From
for purpose          in absence from work affecting                      L  action plan in place.                              Board and PE.             Rates above average.       step by step              L = 3 October
                     the ability to provide services               =4       Family Friendly policies.                          Financial Information                                guidance for               RR = 2007
                     efficiently and safely. Risk                   RR = 12 Counselling Services.                              Management System                                    consistent              9
                     Register 244                                    AMBER Occupational Health                                 (FIMS) reporting across                              application of          AMBER
                                                                            service and Wellbeing                              St HA                                                policies, in addition
                                                                            activities. Sickness                                                                                    to the current
                                                                            Absence monitoring and                                                                                  training programme
                                                                            Policy and Procedure.                                                                                   accessible to
                                                                            Management training                                                                                     Managers.
                                                                            Programme.




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            PF                                              RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                           Updated 26/10/2007




Objective              Risk                                 Mapped Initial      Current Control             Gaps in Control        Current Assurance       Gaps in Assurance   Action Required    Residual   Lead
                                                            to HCC   Risk                                                                                                                         Risk       Director
                                                            Standard Rating                                                                                                                          (C x    Review
                                                            s          (C x L =                                                                                                                   L = )      Date
                                                                     )
3D Workforce           Loss of business from the PCT                  C=4       HR Reports to TB and        Requirement for        HCC review and fitness Board and Bench      Development of         C=3    HHR
                       to the NHS marketplace/another                   L=3     PE FIMS returns             comprehensive          for purpose review         making reports   comprehensive          L=3    March 08
                       provider due to inappropriate                    RR =    Inclusion of Agency         workforce plan         Benchmarking of HR                          workforce plan.
                                                                                                                                                                                                      RR = 9
                       skill mix within workforce leading             12 RED    spend in reports Review     incorporating          indicators through the                      Bench making of
                       to lack of competitiveness and/or                        of skill mix in services.   workforce, financial   FIMs returns A4C                            comparative
                       high reference costs in provider /                       Reference costs.            and service plans.     Benefits realisation plan.                  reference costs to     Yellow
                       commissioners / support                                  Recruitment guidelines.                                                                        assess
                       functions                                                18 week work stream                                                                            competitiveness of
                                                                                reviews.                                                                                       PCT services.
                                                                                                                                                                               To work with
                                                                                                                                                                               Provider services to
                                                                                                                                                                               ensure that all future
                                                                                                                                                                               PCT business plans
                                                                                                                                                                               include identification
                                                                                                                                                                               of associated staff
                                                                                                                                                                               numbers / skills. To
                                                                                                                                                                               work with M&I team
                                                                                                                                                                               to ensure that all
                                                                                                                                                                               service
                                                                                                                                                                               developments
                                                                                                                                                                               include identification
                                                                                                                                                                               of all associated
                                                                                                                                                                               staff numbers/skills.
                                                                                                                                                                               To identify
                                                                                                                                                                               information
                                                                                                                                                                               systems/sources to
                                                                                                                                                                               facilitate
                                                                                                                                                                               identification of
                                                                                                                                                                               potential issues
                                                                                                                                                                               affecting workforce,
                                                                                                                                                                               e.g. labour market
                                                                                                                                                                               intelligence.
                                                                                                                                                                               To maintain
                                                                                                                                                                               processes to control
                                                                                                                                                                               costs associated
                                                                                                                                                                               with the use of
                                                                                                                                                                               agency staff. To
                                                                                                                                                                               scope requirements
                                                                                                                                                                               to embed effective
                                                                                                                                                                               workforce [planning




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            PF                                              RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                              Updated 26/10/2007




Objective              Risk                                 Mapped Initial      Current Control            Gaps in Control           Current Assurance         Gaps in Assurance       Action Required     Residual    Lead
                                                            to HCC   Risk                                                                                                                                  Risk        Director
                                                            Standard Rating                                                                                                                                   (C x     Review
                                                            s          (C x L =                                                                                                                            L = )       Date
                                                                     )
3D Workforce Fit for   Patient safety and service quality   C7e,      C=3       Statutory/mandatory        Not all staff             Annual review of dept.   Not all managers using   Continuing             C=3      PF
purpose Workforce      is compromised as a result of        C11a,       L=4     training/learning          receiving all             L&D plans. Monitoring MY PORTAL to monitor        introduction of          L=3    March
                       non-provision or lack of uptake      C11b,        RR =   programmes for all         mandatory learning        & reporting of staff     attendance.              blended learning to             2008
                                                                                                                                                                                                                RR =
                       of training/learning essential to    C11c      12 RED    clinical & non-clinical    / training. Not all       uptake of                                         rationalise                     Directors/
                       role(s).                                                 staff. Access to           managers using            statutory/mandatory                               mandatory training
                                                                                                                                                                                                              9
                                                                                                                                                                                                                       CE
                       Risk Register 245                                        Learning policy in         dept reporting            training/learning.                                to practicable levels AMBER     Dec 2007
                                                                                operation. Annual          facility via MY           Attendance recorded                               by L&D dept - March
                                                                                PDR/PDP. Quality           PORTAL.                   via MY PORTAL.                                    08. Monitoring &
                                                                                assurance of                                         Twice yearly report on                            remedial action by
                                                                                training/learning                                    uptake of                                         dept managers to
                                                                                packages via subject-                                statutory/mandatory                               ensure staff attend
                                                                                specialists. Quality                                 training/learning to PCT                          mandatory
                                                                                assurance of KSF                                     Risk Management                                   training/learning
                                                                                Outlines & Gateway                                   Committee.                                        activities, inc use of
                                                                                reviews. Record of                                   Staff surveys.                                    MY PORTAL by
                                                                                attendance via MY                                                                                      December 07.
                                                                                PORTAL.

3D Workforce Fit for   Inequitable access/uptake of      C7e,      C=2          *Access to Leaning         *Not all staff            *Staff Survey used to     Need information on     *Continued           C=2        PF (AC)
purpose Workforce      learning/training/development for C11a,       L=4        policy in operation.       receiving annual          monitor staff having      reasons for lack of     promotion of best      L=2      March
                       PCT staff, resulting in reduced   C11c, C8b    RR        *Access provided to        PDR and/or                PDR/PDP. *Quarterly       uptake of PDR &         practice in PDR &               2008
                                                                                                                                                                                                              RR =
                       service quality and low morale              =8           both PCT & Contractor      Gateway Reviews.          reports on staff having   training/learning.      Gateway Reviews                 Sept 2008
                                                                                staff. *Annual learning    *Not all managers         Gateway Reviews by                                by L&D Dept -
                                                                                                                                                                                                            4
                                                                   AMBER                                                                                                                                                   June
                                                                                needs analysis to          applying procedures       Directorate. *Quarterly                           March 08.            GREEN
                                                                                                                                                                                                                       2008
                                                                                identify both service &    & records to ensure       KEF return to DoH.                                *Evaluation of non-
                                                                                Individual needs. *KSF     application of            *PDR training for                                 mandatory training /
                                                                                outlines for each role,    learning by staff.        reviewers & reviewees.                            learning by L&D
                                                                                used at PDR.               *Not all staff have       *Guidance/advice of                               staff - September
                                                                                *Targeted learning         an approved KSF           PDR/KSF via PCT                                   08. *Review of PDR
                                                                                programmes                 Outline for their role.   intranet & L&D                                    by L&D Dept - June
                                                                                commissioned to meet                                 telephone helpline.                               08.
                                                                                needs (e.g. Support                                  *Monitoring & recording
                                                                                Worker development                                   of application of
                                                                                programmes, Managing                                 learning via LAA forms
                                                                                People etc. *PCT                                     & CPD Portfolio for all
                                                                                values and staff charter                             staff. *Monitoring &
                                                                                including development                                reporting of Gateway
                                                                                rights.                                              Reviews.




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            PF                                              RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                         Updated 26/10/2007




Objective                Risk                               Mapped Initial      Current Control           Gaps in Control       Current Assurance         Gaps in Assurance        Action Required    Residual    Lead
                                                            to HCC   Risk                                                                                                                             Risk        Director
                                                            Standard Rating                                                                                                                              (C x     Review
                                                            s          (C x L =                                                                                                                       L = )       Date
                                                                     )
3D Workforce Fit for     New staff unable to fulfil their   C11b      C=3       *Data-base of all new     Not all staff         *Monitoring & reporting   Not all managers         *Continuing           C=2      PF
purpose                  role(s) effectively.                          L=4      starters in operation     attending corporate   of uptake including 6     recording Departmental   promotion of best      L=3     (AC/HW)
                                                                        RR =    (PRISM / ESR).            induction.            monthly CRMC.             induction.               practice in Induction            March
                                                                                                                                                                                                            RR
                                                                      12        *Corporate induction                            *Record of                                         by HR & L & D                  2008
                                                                                procedure in place.                             Departmental Induction                             Depts. - March 08.
                                                                                                                                                                                                         =6
                                                                      AMBER                                                                                                                                       Sept 2008
                                                                                *Departmental induction                         by line managers,                                  *System for line      YELLOW
                                                                                                                                                                                                                    June
                                                                                checklist. *Mandatory                           recorded in personal                               management                     2008
                                                                                training tables published                       file. *HCC and RMS                                 confirmation of
                                                                                for all staff roles. *OD                        standards. *Induction                              corporate and dept
                                                                                and HR Strategy. *PCT                           spot checks of new                                 induction to be
                                                                                priorities include                              starters.                                          explored linked to
                                                                                Workforce Development                                                                              EST.
                                                                                Enabling Programme.
                                                                                *Regular review by
                                                                                Directors. *Workforce
                                                                                Plan as part of LDP.
                                                                                *Record of attendance
                                                                                at corporate induction
                                                                                via MY PORTAL.




3D Workforce Fit for     Workforce not able to respond      C7b/e,    C=3       *OD and HR Strategy.                            *PCT performance                                                      C=3         PF (AC)
Purpose                  effectively to changing            C8b,        L=4     *PCT Priorities include                         including HCC                                                          L=2        Mar 08
                         requirements.                      C11a/c      R R=    Workforce Development                           assessment; Fitness for
                                                                                                                                                                                                        RR
                                                                      12        enabling Programme.                             Purpose and Finnamore
                                                                                *Regular review by                              reviews. *Key Targets
                                                                                                                                                                                                      =6
                                                                      AMBER
                                                                                Directors. *Workforce                           reports. *Staff surveys                                               YELLOW
                                                                                Plan as part of LDP.                            reported to Board and
                                                                                                                                PE.


3E Information / IT /
Intelligence      To
ensure timely relevant
and accurate
reporting to inform
decision making.
Deliver Connecting
for Health (inc NLOP
responsibilities)




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            PF                                          RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                        Updated 26/10/2007




Objective                Risk                           Mapped Initial      Current Control             Gaps in Control     Current Assurance        Gaps in Assurance   Action Required    Residual   Lead
                                                        to HCC   Risk                                                                                                                       Risk       Director
                                                        Standard Rating                                                                                                                        (C x    Review
                                                        s          (C x L =                                                                                                                 L = )      Date
                                                                 )
3F Partnership -
Maintain and develop
good partnership
working with principle
providers / LA / SHA /
Voluntary Sector /
External Agencies




3G To ensure that        Services not being responsive to C16, C17, C = 4      PPE Sub group. PPE      Lack of quality in   6 monthly report to                          Implementation of      C=3    PF/SMH
services                 local need and what people       D8 and          L=   Strategy & action plan. indicators in        Board. Non Executive                         PPE action plan.        L=3    JR/CS
commissioned and         want.                            D11a      3          Links with Overview and contracts            Committee for PPE.                                     Inclusion of
                                                                                                                                                                                                  RR = March 08
provided are                               Risk Register            RR = 12    Scrutiny. PPE Toolkit.                       Feedback from O+S.                           quality indicators in
                         248                                                   Joint LA/PCT.                                Healthcare Commission                        contacts.
                                                                                                                                                                                                9
responsive to                                                        RED
                                                                               Consultation protocol.                       assessment . Patient                                            AMBER
patient's needs and
wishes.                                                                        Monitoring of PALS and                       survey satisfaction -
                                                                               complaints / compliment                      Access survey to board
                                                                               information                                  September 07.




    STRATEGIC OBJECTIVE                                 4. TO IMPROVE HEALTH SERVICES ACROSS ROTHERHAM VIA OWN PROVIDER FUNCTION
Cross reference to 3
where appropriate




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            KH                                         RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                       Updated 26/10/2007




Objective                Risk                          Mapped Initial      Current Control           Gaps in Control      Current Assurance        Gaps in Assurance         Action Required       Residual   Lead
                                                       to HCC   Risk                                                                                                                               Risk       Director
                                                       Standard Rating                                                                                                                                (C x    Review
                                                       s          (C x L =                                                                                                                         L = )      Date
                                                                )
What the organisation What could prevent this          e.g. C1(a)             What controls/         Where we are         Where we can gain        Where we are failing to   What needs to be
aims to deliver       objective being achieved                                systems we have in     failing to put       evidence that our        provide evidence that     carried out to
                      RR=Risk Register                                        place to assist in     controls / systems   controls/ systems, on    our controls /            reduce the risk. By
                                                                              securing delivery of   in place             which we are placing     assessments are           when
                                                                              our objectives.                             reliance are effective   effective


    STRATEGIC OBJECTIVE                               1. TO IMPROVE THE HEALTH AND WELL BEING OF THE ROTHERHAM POPULATION
1A To reduce health
inequalities - 2010
targets short term

1B To reduce health
inequalities in the
medium to long term

1C Safeguarding
Health in Emergency
Planning / Service
Continuity

1D Delivering
Community wide
health regeneration
through working with
external agencies /
sectors


    STRATEGIC OBJECTIVE                               2. TO IMPROVE HEALTH SERVICES ACROSS ROTHERHAM
2A To deliver existing
and new national
targets




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            KH                                         RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                           Updated 26/10/2007




Objective                Risk                          Mapped Initial      Current Control   Gaps in Control   Current Assurance   Gaps in Assurance   Action Required   Residual   Lead
                                                       to HCC   Risk                                                                                                     Risk       Director
                                                       Standard Rating                                                                                                      (C x    Review
                                                       s          (C x L =                                                                                               L = )      Date
                                                                )
2B To effectively
commission first
class services for
Primary, Secondary
and Tertiary Services,
including out of hours
and emergency care
e.g. Commissioning
for patient safety.
Quality and patient
experience



2 C To meet National
Standards including
Healthcare
Commission
development
standards


    STRATEGIC OBJECTIVES                              3. TO ENSURE EFFECTIVE GOVERNANCE AND LEADERSHIP TO DELIVER PCT PURPOSE
3A Finance -
Statutory duties
       ALE
3B Legal - To comply
with all legal
requirements
3C Estates - To
provide fitness for
purpose premises
3D Workforce




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            KH                                         RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                           Updated 26/10/2007




Objective                Risk                          Mapped Initial      Current Control   Gaps in Control   Current Assurance   Gaps in Assurance   Action Required   Residual   Lead
                                                       to HCC   Risk                                                                                                     Risk       Director
                                                       Standard Rating                                                                                                      (C x    Review
                                                       s          (C x L =                                                                                               L = )      Date
                                                                )
3E Information / IT /
Intelligence      To
ensure timely relevant
and accurate
reporting to inform
decision making.
Deliver Connecting
for Health (inc NLOP
responsibilities)


3F Partnership -
Maintain and develop
good partnership
working with principle
providers / LA / SHA /
Voluntary Sector /
External Agencies




3G Public / Patient
Engagement / Patient
Experience
    STRATEGIC OBJECTIVE                               4. TO IMPROVE HEALTH SERVICES ACROSS ROTHERHAM VIA OWN PROVIDER FUNCTION




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            KH                                            RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                       Updated 26/10/2007




Objective               Risk                              Mapped Initial      Current Control          Gaps in Control      Current Assurance         Gaps in Assurance        Action Required       Residual   Lead
                                                          to HCC   Risk                                                                                                                              Risk       Director
                                                          Standard Rating                                                                                                                               (C x    Review
                                                          s          (C x L =                                                                                                                        L = )      Date
                                                                   )
4A To achieve 'arms     Governance arrangements do                  L=3       (1)Trust (Provider)                           (1)Separate Trust Board (1)Review of arms          (1)Option appraisal   L=2        To be
length arrangements'    not achieve 'arms length                              Board meets once every                        agenda for Provider and length arrangement and     for model of                     completed
for Provider Services   arrangements' for Provider                  C=3       2 months with separate                        Commissioning mode.     appraisal of model of      provision for         C=2        by March
with PCT                Services.                                             Trust Board agenda                                                    provision                  Rotherham PCT                    2008
                                     Risk Register 249              RR=9      (From commissioning                                                   (2)Progress against        Provider Services     RR=4       KH
                                                                    AMBER     agenda).                                                              Business Plan not                  (2)Action
                                                                                      (2) Core                                                      monitored                  Plan and monitoring   GREEN
                                                                              Management Team                                                                                  at CMT meetings
                                                                              established which is                           (2)Buisness Plan                                  and reports to
                                                                              responsible for all                           agreed at PCT Provider                             Provider Services                Dec 07
                                                                              functions within the                          Board.                                                                              KH
                                                                              Directorate                                           (3)Core
                                                                                                                            Management Team
                                                                                                                            Terms of Reference
                                                                                                                            agreed by Trust Board
                                                                                                                            and meetings held
                                                                                                                            monthly.
                                                                                                                                        (4)HCC
                                                                                                                            compliance against
                                                                                                                            standards monitored for
4B Successful           Directorate does not meet the               L=3       Monthly meetings with    Need to operate in Terms of Reference of                                Minutes from          L=2        KH
performance             requirements of the 2007/08                    C=3    contracting team         operational/         both types of                                      meetings to go to                Mar 08
                        Service Level Agreement.                                                       strategic mode at    contracting meetings                               Provider CMT          C=3
against 2007/08
                                      Risk Register 250             RR=9                               every other meeting. reviewed                                           monthly Business
Service Level                                                         AMBER                                                                                                    mtg as part of        RR=6
Agreement with                                                                                                                                                                 performance
PCT                                                                                                                                                                            monitoring            YELLOW
Commissioners
                                                                              Performance against                           (1)reports and minutes  No integrated              Balanced' score                  Jan 08 KH
                                                                              contract monitored by                         from Core Management performance report            card approach to be
                                                                              Head of Business unit                         Team meetings.         combining activity and      incorporated in
                                                                              and Core Management                                (2)Report to      quality                     reporting to CMT
                                                                              Team(CMT).                                    Provider Board                                     and Provider Board


                                                                              Performance against                           Reports to CMT and to     CRES not fully identified Plan to achieve                 End of
                                                                              Budget monitored by                           Provider Board            or achieved               CRES required                   Nov 2007
                                                                              CMT, Senior Managers                                                                                                              KH
                                                                              and Heads of Dept




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            KH                                           RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                        Updated 26/10/2007




Objective              Risk                              Mapped Initial      Current Control           Gaps in Control      Current Assurance         Gaps in Assurance          Action Required          Residual   Lead
                                                         to HCC   Risk                                                                                                                                    Risk       Director
                                                         Standard Rating                                                                                                                                     (C x    Review
                                                         s          (C x L =                                                                                                                              L = )      Date
                                                                  )
4C Implementation      Impact upon service continuity    C9        L=4        (1) Project Board in                          (1) Meetings held and     (3) Review not yet         (3) Review to be         L=3       KH
of System One/TPP      during implementation of a new                C=4      Place                                         minutes recorded      .   completed                  completed                      C=3 Mar 08
                       community connecting for health                        (2) Project Initiation                        Project Plan
connecting for
                       compliant IT system.                        RR=16      Document (Community                           (Implementation) in                                                           RR=9
Health compliant IT    Risk Register 251                              RED     and Child Health) plan                        place and in progress.
system                                                                        in place                                                (2)System                                                           AMBER
                                                                                                                            data and quality
                                                                                                                            monitored
                                                                                                                            (3) 6/12 monthly review
                                                                                                                            of records planned


                                                                                                                            Risk Register reviewed    Concern of impact upon     Implementation plan                 Dec 07 KH
                                                                                                                            by Project Board          frontline staff capacity   'tailored' to relevant
                                                                                                                                                                                 department.
                                                                                                                                                                                 Pilot in use of
                                                                                                                                                                                 mobile technology


                                                                                                                                                      Final templates and        Documentation                       Mar 08
                                                                                                                                                      paperlight system          templates to be                      KH
                                                                                                                                                      require approval by        finalised and
                                                                                                                                                      appropriate governance     approved
                                                                                                                                                      mechanism


                                                                                                       Maintained plan                                System maintenance/        Plan to be                          Dec 07 KH
                                                                                                       (following                                     plan continuity required   developed for one
                                                                                                       implementation) to                                                        implementation
                                                                                                       be in place                                                               complete




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            KH                                             RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                          Updated 26/10/2007




Objective               Risk                               Mapped Initial      Current Control            Gaps in Control       Current Assurance          Gaps in Assurance           Action Required         Residual    Lead
                                                           to HCC   Risk                                                                                                                                       Risk        Director
                                                           Standard Rating                                                                                                                                        (C x     Review
                                                           s          (C x L =                                                                                                                                 L = )       Date
                                                                    )
4D to ensure clinical   Directorate fails to meet Health   Hygiene  L=5        (1)Infection Control                             (1)Minutes received by     (1)Breathing Space now      (1)Review against       L=3       Dec-07
quality and patients    Act compliance and new             Code        C=4     Committee                                        clinical governance        operational and             Infection Control             C=4 KH
safety in accordance    Decontamination requirements.      duties                     (2)Director for                           committee                  assessment against          requirements
with Healthcare         Risk Register 252                  1=11 C4C RR=20      Infection Prevention and                                 (2)Annual Report   standards to be             (2)Implement            RR=12
Commission                                                 C21 C4a    RED      Control                                          to Trust board             completed. Regular          recommendations.           RED
Standards                                                                      (3)Infection Control                                        (3) NHSLA       review in light of
                                                                               Control Team                                     Level 1 achieved           increasing patient          (3)Regular
                                                                                     (4)Mandatory                                                          activity                    monitoring and audit
                                                                               Infection Control                                (4)Evidence against                        (2)Review   of in patient areas
                                                                               Training and Updates                             HCC standards              requirement against         including Breathing
                                                                                                                                    (5)DIPC attends        Health Act requirements     Space
                                                                               (5)Handwashing/                                  Trust Board + job desc.    to ensure all procedures           (4)Procedures
                                                                               Infection Control                                                  (5)      and systems in place are    to be approved and
                                                                                                                                Infection Control          up to date                  implemented
                                                                                                                                Policies and Procedures




                                                                               Plan for Risk              All services do not   (1)Single use            Declaration of lapse and      Trust Board to be                   Mar-08
                                                                               minimisation within        comply with new       instruments and CSSD action plan                       updated re current                  KH
                                                                               services agreed at Trust   Decontamination       used whenever                                          lapse.
                                                                               Board                      standards             possible.                                              Tendering process
                                                                                                                                (2)Risk areas minimised                                and new contract to
                                                                                                                                as far as possible until                               be in place by
                                                                                                                                tender of revised                                      March 08
                                                                                                                                service completed.


4D to ensure clinical   Children may be harmed due to      C9        L=3       (1)Professional record     (1)Not possible to    (1)Provider Board        (1)achievement of action      (1)Investigation root   L=3         Apr-08 KH
quality and patients    unavailable/missing clinical                    C=4    keeping standards          track all record      informed of significant  plan                          cause analysis and            C=3
safety in accordance    records of children.                                      (2) Clinical Records    movements             lapse, root cause                                      action plan to be
with Healthcare                Risk Register 253                     RR=12     Committee                                        analysis and action plan                               completed/               RR=9
Commission                                                            RED      (3)Medical Records                               developed to address                                   achieved.
Standards                                                                      Policy                                           lapse                                                  (2)Improve records      AMBER
                                                                                                                                                                                       management in line
                                                                                                                                                                                       with implementation
                                                                                                                                                                                       of electronic
                                                                                                                                                                                       healthcare record
                                                                                                                                                                                       system (TPP)




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            KH                                           RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                          Updated 26/10/2007




Objective               Risk                             Mapped Initial      Current Control                Gaps in Control   Current Assurance        Gaps in Assurance           Action Required       Residual   Lead
                                                         to HCC   Risk                                                                                                                                   Risk       Director
                                                         Standard Rating                                                                                                                                    (C x    Review
                                                         s          (C x L =                                                                                                                             L = )      Date
                                                                  )
4D to ensure clinical   Failure to safeguard children.   C2        L=4     (1)Child Protection                                (1)Clinical Governance   (1)Up to date audit of      (1)Audit to be        L=3        Dec 08
quality and patients    Risk Register 254                              C=5 Procedures                                         Development Plan         safeguarding                completed
safety in accordance                                                       (2)Safeguarding Board                              (2)Child Health          arrangements in             (2)Arrangements to    C=5
with Healthcare                                                    RR=20                                                      Protection Forum         accordance with             be reviewed as part
Commission                                                                 (3)Designated and                                  (3)Agreed training       Children's Act              of Children's Trust   RR=15
Standards                                                                  named Professionals for                            programme                    (2) Outstanding         arrangements                      March 08
                                                                           safeguarding                                       (4)Child protection      actions against part 8                                        KH
                                                                                                                              supervision and local    reviews.
                                                                                                                              standards


4E Integrated           Risk that new arrangements for   C2 all    L=2         PCT Board and                                  Reports to PCT Board     Final proposal /            (1)Final proposal /   L=3    Dec 08
Frontline Service       commissioning/ provision of      domains         C=5   partnership structure                          and Children's Board     business case in relation   Business case to be
delivery as part of     C&YP services do not enable      of HCC                including CEO, Non                                                      to Childrens' Trust         agreed by PCT         C=3    March 08
Children's Trust        PCT to meet 5 key tests:-                  RR=10       Executive and Lead                                                      arrangements.               Board                    RR=9 March
arrangements                             (a) Statutory                         Director                                                                Commissioning contract                  (2) To           08 KH
                        duties discharge                                       Childrens Board work                                                    PCT/ RMBC required          complete contract
                         (b)Outcomes are improved for                          programme part of PCT                                                              Provision                        (3)To
                        children and young people                              corporate priority                                                      SLA RMBC/PCT                complete SLA
                        (c)new arrangements are safe                           programme                                                               provider required
                                                (d)Human                       Children and Young
                        resources                                              People's plan.
                        arrangement are robust                                 Consultation for frontline
                          (e) Arrangements are                                 integration undertaken
                        affordable.                                            and now complete
                                      Risk Register 255




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            JR                                             RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                             Updated 26/10/2007




Objective              Risk                                Mapped Initial      Current Control           Gaps in Control          Current Assurance         Gaps in Assurance          Action Required       Residual   Lead
                                                           to HCC   Risk                                                                                                                                     Risk       Director
                                                           Standard Rating                                                                                                                                      (C x    Review
                                                           s          (C x L =                                                                                                                               L = )      Date
                                                                    )
What the organisation What could prevent this              e.g. C1(a)           What controls/           Where we are             Where we can gain         Where we are failing to    What needs to be
aims to deliver       objective being achieved                                  systems we have in       failing to put           evidence that our         provide evidence that      carried out to
                      RR=Risk Register                                          place to assist in       controls / systems       controls/ systems, on     our controls /             reduce the risk. By
                                                                                securing delivery of     in place                 which we are placing      assessments are            when
                                                                                our objectives.                                   reliance are effective    effective


    STRATEGIC OBJECTIVE                                    1. TO IMPROVE THE HEALTH AND WELL BEING OF THE ROTHERHAM POPULATION
1A To reduce health    Unlikely to meet the reduction in   C22          L=5     NST Action Plan          1) NST Action Plan       1) NST Action Plan        Mortality data not "real   Fully implement the   L=4        JR Mar 08
inequalities - 2010    the gap of life expectancy                       C=4                              not yet fully            reports to Board          time"                      NST Action Plan       C=4
targets short term     required to meet 2010 target as                  RR=20                            implemented              quarterly                                                                  RR=16
                       the amount of improvement is                      RED                                  2) Some                 2) 3 year average                                                      RED
                       not in line with national                                                         trajectories are         mortality updates
                       trajectories (i.e. speed).                                                        beyond PCT control
                                 Risk Register 215                                                       e.g. Poverty


1B To reduce health    Despite interventions i.e. NST      C22          L=4     Rotherham Public         1) Public Health         1) Reports to LSP via     Reports to PCT Board       Review reporting      L=3        JR Mar 08
inequalities in the    action Plan the gap in                           C=4     Health Strategy          Strategy not yet fully   Alive Board.                                         mechanisms            C=4
medium to long term    inequalities is not closing.                     RR=16                            implemented              2) Annual DPH Report                                 Continue to work       RR=12
                                                                         RED                              2) Health Services                  3) Internal                              with partner           Amber
                                      Risk Register 216                                                  not the major            monitoring group                                     organisations
                                                                                                         determinant -            established
                                                                                                         depends on
                                                                                                         economic
                                                                                                         performance/partner
                                                                                                         ship etc

1C Safeguarding        Emergency response of the PCT C24                L=3     1) Annual Plan agreed    Unable to determine 1) Joint Health & Social None                             Ongoing actions       L=2        JR Dec 08
Health in Emergency    inadequate.                                      C=5     by the Board covering    all types of        Care Emergency                                                                  C=5
Planning / Service      Risk Register 218                               RR=15   most contingencies       emergency faced by Planning Group in place                                                          RR=10
Continuity                                                              RED                2)Emergency   the PCT                                 2)                                                          Amber
                                                                                Planning tested                              PCT Planning Group.
                                                                                annually and reviewed                                         3)
                                                                                in recent emergencies                        Board receive an
                                                                                                                             annual update on
                                                                                                                             Emergency Planning.




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            JR                                            RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                          Updated 26/10/2007




Objective               Risk                              Mapped Initial      Current Control            Gaps in Control       Current Assurance          Gaps in Assurance        Action Required       Residual   Lead
                                                          to HCC   Risk                                                                                                                                  Risk       Director
                                                          Standard Rating                                                                                                                                   (C x    Review
                                                          s          (C x L =                                                                                                                            L = )      Date
                                                                   )
1C Safeguarding         Emergency response of the PCT C24           L= 5      Local Risk Register        Reporting          1) PCT Emergency              Mechanisms for           Review reporting      L=2        JR Dec 08
Health in Emergency     does not consider risks identified          C=4       developed in relation to   mechanisms for     Planning Group                reporting to PCT Board   mechanisms            C= 4
Planning / Service      throughout the health                       RR = 20   the South Yorkshire        emergency planning    2) Joint health &                                   Continue to work      RR=8
Continuity              community.                                  RED       Risk Register. Agreed      risk register      social Care PCT                                        with partner           Amber
                                  Risk Register 219                           by PCT Emergency                              Emergency Planning                                     organisations
                                                                              Planning Groups                               Group


1C Safeguarding          Risk in relation to lack of      C24       L= 5      Local Risk Register        In relation to        Use of Satellite           To ensure the PCT and    Generator plan to be L=2         JR Dec 08
Health in Emergency     generator back up in key                    C=4       developed in relation to   generator Head of     telephone technology       NHS in Rotherham is      developed by         C= 4
Planning / Service      buildings. (RPCT Risk register              RR = 20   the South Yorkshire        Estates to write a    with a 3k grant from the   represented at the       November 2007.       RR=8
Continuity              for Emergency Planning).                     RED      Risk Register. Agreed      Generator action      SHA. Head of Estates       RMBC fuel strategy                            Amber
                                          Risk Register                       by PCT Emergency           plan by November      coordinating purchasing    meeting as they know
                        220                                                   Planning Groups            2007. Possible        and installation           how to coordinate all    Attendance at Fuel
                                                                                                         generators to be                                 essential users in       strategy meeting by
                                                                                                         sought for Oak                                   Rotherham                a representative
                                                                                                         House and the new                                                         from NHS estates
                                                                                                         PCC. Fuel - Head of
                                                                                                         Estates to attend
                                                                                                         fuel management
                                                                                                         meetings led by
                                                                                                         RMBC on behalf of
                                                                                                         the NHS




    STRATEGIC OBJECTIVE                                   2. TO IMPROVE HEALTH SERVICES ACROSS ROTHERHAM
2A To deliver existing Obesity - Service provision does   C23       L=5       1) Choosing Health         Monitoring of         Monitoring of Obesity      Plan not fully           Reflected in future   L=5        JR Mar 08
and new national       not currently meet need.                     C=4       Delivery Plan              Obesity Strategy      Strategy                   implemented yet          LDPs                  C=4
targets                                  Risk                       RR=20     2) Obesity strategy        and L.D.P.                                                                                       RR=20
                       Registered 225                               RED              3) Procurement                                                                                                       RED
                                                                              Process




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            JR                                               RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                        Updated 26/10/2007




Objective                Risk                                Mapped Initial      Current Control           Gaps in Control      Current Assurance      Gaps in Assurance         Action Required     Residual   Lead
                                                             to HCC   Risk                                                                                                                           Risk       Director
                                                             Standard Rating                                                                                                                            (C x    Review
                                                             s          (C x L =                                                                                                                     L = )      Date
                                                                      )
2B To effectively        Current commissioning strategy                L=5       Enhancement of quality    Some standards       Board reports          Current Board reports     Define standards      L=3      CS/JR
commission first         emphasizes numbers and                        C=3       standards and             developed however                           have more information     agree the process     C=5      Mar 08
class services for       waiting times rather than patient             RR=15     monitoring in             further work on                             on volume than quality    for monitoring ,       RR=15
Primary, Secondary       experience and quality. The                    RED      commissioning             more standards                                                        ensure they're in the RED
and Tertiary Services,   standards are required to ensure                                                  need to be                                                            contract and monitor
including out of hours   the information is available for                                                  undertaken not yet                                                    against them
and emergency care       the next round of contracting.                                                    in place
e.g. Commissioning                          Risk Register
for patient safety.      230
Quality and patient
experience




2 C To meet National     The organisation does not         All         L=3       Process in place to       Electronic Solution Healthcare Commission   Evaluation of the         Systematic             L=3     JR Dec 08
Standards including      achieve sufficient assurance that             C=5       monitor evidence          requires further    Steering Group          evidence base             evaluation to be        C=5
Healthcare               all standards are being achieved.              RR=15    through Healthcare        development across Reports to PCT Board     unsystematic across the   developed.               RR=15
Commission                                                              RED      Commission Steering       the organisation                            organisation              Electronic solutions     RED
development                                       Risk                           Group. Director                                                                                 to be explored further
standards                Register 233                                            Responsibility for each
                                                                                 standard identified.


    STRATEGIC OBJECTIVES                                     3. TO ENSURE EFFECTIVE GOVERNANCE AND LEADERSHIP TO DELIVER PCT PURPOSE
3A Finance -
Statutory duties
       ALE
3B Legal - To comply Reduction in funding will mean                    L=4       PAG to demonstrate                             Regular reporting to                             Governance          L=3     JR Dec 08
with all legal       PCT has to take more risks in                     C=4       due process                                    Board and non-exec                               arrangements need   C=5
requirements         cost per case decisions.                          RR=16                                                    Chairing of Appeals                              to be clarified      RR=16
                                    Risk Register 238                  RED                                                                                                                               L=3

                                                                                                                                                                                                     C=4
                                                                                                                                                                                                     RR=12




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            JR                                           RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                             Updated 26/10/2007




Objective                Risk                            Mapped Initial      Current Control              Gaps in Control       Current Assurance       Gaps in Assurance           Action Required       Residual   Lead
                                                         to HCC   Risk                                                                                                                                    Risk       Director
                                                         Standard Rating                                                                                                                                     (C x    Review
                                                         s          (C x L =                                                                                                                              L = )      Date
                                                                  )
3B Legal - To comply High profile lapse in Child                   L=4        1) Safeguarding policies                          Reports to Children's   1) Governance               1) Governance         L=5        JR Dec 08
with all legal       Protection leading to a child                 C=4        and procedures                                    Board and PCT Board     arrangements could be       arrangements need     C=4
requirements         suffering harm.                               RR=16                  2)                                                            confused during             to be clarified        RR=20
                                Risk Register 239                   RED       Safeguarding Board                                                        Integration of Children's     2) Serious Case      RED
                                                                                         3) Training                                                    Services                    Reviews to be
                                                                              requirement for all                                                              2) Serious Case      reviewed by CGC
                                                                              clinical and non clinical                                                 Reviews to be reported
                                                                              staff agreed                                                              to Clinical Governance
                                                                                                                                                        Committee (CGC)



3C Estates - To
provide fitness for
purpose premises
3D Workforce
3E Information / IT /  Board do not receive systematic             L=5        Extensive analysis          Lack of prioritisation Ad hoc reporting to                                Strategic             L=2        AB
Intelligence      To   intelligence required to make               C=3        already taking place        in reports that        Board                                              Intelligence Review   C=3        Mar 08
ensure timely relevant effective decisions.                        RR=15                                  Board receives                                                            from November 07       RR=6
and accurate                    Risk Register 246                  RED                                                                                                                                     Yellow
reporting to inform
decision making.
Deliver Connecting
for Health (inc NLOP
responsibilities)


3F Partnership -
Maintain and develop
good partnership
working with principle
providers / LA / SHA /
Voluntary Sector /
External Agencies




3G Public / Patient
Engagement / Patient
Experience
    STRATEGIC OBJECTIVE                                  4. TO IMPROVE HEALTH SERVICES ACROSS ROTHERHAM VIA OWN PROVIDER FUNCTION




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            JR                                         RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                           Updated 26/10/2007




Objective              Risk                            Mapped Initial      Current Control   Gaps in Control   Current Assurance   Gaps in Assurance   Action Required   Residual   Lead
                                                       to HCC   Risk                                                                                                     Risk       Director
                                                       Standard Rating                                                                                                      (C x    Review
                                                       s          (C x L =                                                                                               L = )      Date
                                                                )
Cross reference to 3
where appropriate




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            CS                                                 RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                        Updated 26/10/2007




Objective                Risk                                  Mapped Initial      Current Control            Gaps in Control      Current Assurance        Gaps in Assurance         Action Required       Residual   Lead
                                                               to HCC   Risk                                                                                                                                Risk       Director
                                                               Standard Rating                                                                                                                                (C x L   Review
                                                               s          (C x L =                                                                                                                          = )         Date
                                                                        )
What the organisation What could prevent this                  e.g. C1(a)             What controls/          Where we are         Where we can gain        Where we are failing to   What needs to be
aims to deliver       objective being achieved                                        systems we have in      failing to put       evidence that our        provide evidence that     carried out to
                      RR=Risk Register                                                place to assist in      controls / systems   controls/ systems, on    our controls /            reduce the risk. By
                                                                                      securing delivery of    in place             which we are placing     assessments are           when
                                                                                      our objectives.                              reliance are effective   effective


    STRATEGIC OBJECTIVE                                        1. TO IMPROVE THE HEALTH AND WELL BEING OF THE ROTHERHAM POPULATION
1A To reduce health
inequalities - 2010
targets short term

1B To reduce health
inequalities in the
medium to long term

1C Safeguarding
Health in Emergency
Planning / Service
Continuity

1D Delivering
Community wide
health regeneration
through working with
external agencies /
sectors


    STRATEGIC OBJECTIVE                                        2. TO IMPROVE HEALTH SERVICES ACROSS ROTHERHAM
2A To deliver existing   Insufficient contracted activity to   C7f          C=4       FACT use internal and   None                 Board Performance        None                      None                  C=4      CS
and new national         meet the targets.                                    L=3     external models to                           Report                                                                     L=2    MAR 08
targets                  Risk Register 221                                            calculate required                                                                                                        RR =
                                                                            RR = 12   activity.                                                                                                             8
                                                                             RED                                                                                                                            AMBER


2A To deliver existing   Service providers fail to deliver     C7f          C=4       Monthly monitoring of   None                 Board Performance        None                      Develop potential     C=4        CS
and new national         contracted requirements.                           L=3       contracts by FACT                            Report                                             alternative providers   L=2      MAR 08
targets                  Risk Register 222                                  RR = 12                                                                                                   and capacity.             RR
                                                                            RED                                                                                                                             =8
                                                                                                                                                                                                            AMBER




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            CS                                                 RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                   Updated 26/10/2007




Objective                 Risk                                 Mapped Initial      Current Control          Gaps in Control   Current Assurance        Gaps in Assurance   Action Required         Residual   Lead
                                                               to HCC   Risk                                                                                                                       Risk       Director
                                                               Standard Rating                                                                                                                       (C x L   Review
                                                               s          (C x L =                                                                                                                 = )         Date
                                                                        )
2A To deliver existing    Services are not redesigned          C7f       C=3       18 Week Group review     None              18 Week Group reports    None                Incorporation of        C=3    CS
and new national          where appropriate.                             L=4       of services.                               to Directors.                                redsign work into         L=3  MAR 08
targets                   Risk Register 223                              RR = 12                                                                                           mainstream                  RR
                                                                         AMBER                                                                                             commissioning           =9
                                                                                                                                                                           processes.              AMBER


2A To deliver existing    LDP fails to allocate necessary      C7f       C=4       LDP group makes          None              Board Performance        None                Review of the LDP       C=4      CS
and new national          resources to key target areas.                 L=4       recommendations to                         Report                                       processes.                L=3    MAR 08
targets                   Risk Register 224                              RR = 16   Directors, PE and then                                                                                              RR =
                                                                         RED       the Board                                                                                                       12
                                                                                                                                                                                                   RED
2B To effectively         Commissioning decisions are not C7d            C=4       Skilled contracting team None              Monthly meeting          None                Contracting skills to   C=4      CS
commission first class    incorporated into contracts with               L=4       are kept up to date of                     between FACT and                             be developed and         L=3     MAR 08
services for Primary,     the required levers and                        RR = 16   commissioning                              Strategic Development.                       up dated regularly.         RR =
Secondary and Tertiary    flexibilities.                                 RED       intentions.                                                                                                     12
Services, including out   Risk Register 228                                                                                                                                                        RED
of hours and
emergency care e.g.
Commissioning for
patient safety. Quality
and patient experience



2B To effectively         The market does not have             C7f       C=3       Commissioning              None            Y&H meetings (annual     None                Prepare a market       C=3         CS
commission first class    providers available to deliver the             L=3       intentions are notified to                 review, CE, DOFs)                            development              L=2       MAR 08
services for Primary,     required level of services.                    RR = 9    the main providers for                     provide evidence of                          strategy to align with     RR
Secondary and Tertiary    Risk Register 229                              AMBER     them to develop as                         market providers                             the commissioning      =6
Services, including out                                                            needed .                                   available elsewhere.                         intentions.            YELLOW
of hours and
emergency care e.g.
Commissioning for
patient safety. Quality
and patient experience



2 C To meet National
Standards including
Healthcare
Commission
development standards




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             CS                                            RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                                      Updated 26/10/2007




Objective                Risk                              Mapped Initial      Current Control         Gaps in Control     Current Assurance       Gaps in Assurance   Action Required       Residual   Lead
                                                           to HCC   Risk                                                                                                                     Risk       Director
                                                           Standard Rating                                                                                                                     (C x L   Review
                                                           s          (C x L =                                                                                                               = )         Date
                                                                    )

     STRATEGIC OBJECTIVES                                  3. TO ENSURE EFFECTIVE GOVERNANCE AND LEADERSHIP TO DELIVER PCT PURPOSE
3A Finance - Statutory   Funds are used to finance the     C7d       C=4       Medium term financial   None                Board to approve the   None                 Set up a financial    C=4     CS
duties                   PCT objectives beyond what is               L=4       plan                                        medium term financial                       investement control      L=3  MAR 08
ALE                      affordable recurrently.                     RR = 16                                               plan.                                       process wherby all         RR
                         Risk Register 234                           RED                                                   ALE Assessment 06/07 -                      Directors, PE and     = 12
                                                                                                                            Level 3 Good                               Board investement     RED
                                                                                                                                                                       proposals are
                                                                                                                                                                       signed off by the
                                                                                                                                                                       finance department




3A Finance - Statutory   Expenditure is incurred without   C7d       C=4       Directors and PE review Business planning    Monitoring of new      None                Development of a      C=4    CS
duties                   reference to value for money.               L=4       of business plans.      template required to developments through                       business planning       L=2  MAR 08
ALE                      Risk Register 235                           RR = 16                           cover VFM            FACT                                       template.                 RR
                                                                     RED                                                        ALE - level 3                                                =8
                                                                                                                                                                                             AMBER


3A Finance - Statutory   Commissioning decisions are       C7d       C=4       Directors and PE review Business planning    Monitoring of new      None                Development of a      C=4      CS
duties                   based on poor financial and                 L=4       of business plans.      template required to developments through                       business planning       L=2    MAR 08
ALE                      activity data.                              RR = 16                           cover VFM            FACT                                       template.                 RR =
                         Risk Register 236                           RED                                                        ALE - level 3                                                8
                                                                                                                                                                                             AMBER


3A Finance - Statutory   Financial skills at Board,        C7d       C=3       PDR sysytem of          None                L&D department          None                Use Y&H Finance       C=3        CS
duties                   management and finance                      L=3       indentifying training                       monitoring.                                 Staff Development      L=2       MAR 08
ALE                      department levels are                       RR = 9    needs.                                                                                  system to best effect. RR = 6
                         inadequate.                                 AMBER
                         Risk Register237                                                                                                                                                    YELLOW
3B Legal - To comply
with all legal
requirements
3C Estates - To
provide fitness for
purpose premises
3D Workforce




             D:\Docstoc\Working\pdf\ce227177-d511-40fd-9275-06d03c6f7b33.xls                                                                                                                      46 of 47
            CS                                         RISK ASSURANCE FRAMEWORK - ANALYSIS OF RISK                           Updated 26/10/2007




Objective                Risk                          Mapped Initial      Current Control   Gaps in Control   Current Assurance   Gaps in Assurance   Action Required   Residual   Lead
                                                       to HCC   Risk                                                                                                     Risk       Director
                                                       Standard Rating                                                                                                     (C x L   Review
                                                       s          (C x L =                                                                                               = )         Date
                                                                )
3E Information / IT /
Intelligence      To
ensure timely relevant
and accurate reporting
to inform decision
making. Deliver
Connecting for Health
(inc NLOP
responsibilities)


3F Partnership -
Maintain and develop
good partnership
working with principle
providers / LA / SHA /
Voluntary Sector /
External Agencies


3G Public / Patient
Engagement / Patient
Experience
    STRATEGIC OBJECTIVE                               4. TO IMPROVE HEALTH SERVICES ACROSS ROTHERHAM VIA OWN PROVIDER FUNCTION
Cross reference to 3
where appropriate




            D:\Docstoc\Working\pdf\ce227177-d511-40fd-9275-06d03c6f7b33.xls                                                                                                   47 of 47

				
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Description: Initial Risk Management Strategy document sample