Likeli Score Controls Gaps in control or action required Assurances Future actions. 3- Possibl e. Major. Major. management. Governance Manager

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1 9th Sptmbr 2014 Rsponsibl Dirctorat Natur of Risk Objctivs Risk Risk Dtail DGC - Dirctor of 01 - Complianc Organisational Govrnanc and xcllnc Complianc R Ensuring CCG oprations ar compliant with Information Govrnanc standards On an annual basis, th CCG must dmonstrat that it has implmntd and maintaind IG rlatd policis, procdurs and working practics to a standard ncssar to achiv a satisfactor (.g. lvl 2 or abov) lvl of complianc with all rquirmnts of th NHS Information Govrnanc Toolkit, th Data Protction Act, th Caldicott Principls and othr rlvant guidanc/lgislation or th CCG or its staff ma b subjct to lgal action, loss of rputation, and invstigation b rgulators. Rating Rating Inhrnt Currn Currn Currn Targt Impact Likli Scor Impact Likli Scor Impact Likl Targt Targt Likli Scor Controls Gaps in control or action rquird Assurancs Futur actions 1-Rar 4 C IG toolkit complianc 114 Dvlopmnt of 2014/15 IG work Monthl rviw undrtakn b programm and dtaild IG Managr during 14/15 an d C Local incidnt rporting and milstons for Quartr 1 (April to rportd to Qualit & Clinical managmnt Jun) in progrss Govrnanc Committ. IG Complianc Audits (RSS and Q1/2 of 2014/15 - Indpndnt C Substantiv Information Childrn s Srvics) to b Auditors rviw of CCG Govrnanc Managr compltd during Q2 14/15 rspons to prviousl IG/ICT Scurit Assuranc idntifid aras of concrn and C Govrning Bod rports and rporting schdul with CSU to rviw of vidnc uploadd xcutiv updats b agrd during Q2 14/15 for ICT Assuranc rlatd IGT Dvlopmnt of ntwork of rquirmnts. C End of ar complianc Information Govrnanc CCG to mak full intrim IGT audit Champions across CCG during submission in Octobr 2014 Q2 14/15 C Data flow mapping Intrim submission of 2014/15 IGT rturn for CCG (nonmandator) 30/10/14. C Siro and Caldicott Guardian in post A Draft mobil dvics polic (Danil Lo Russo, 31/10/2014, ) A Dvlopmnt of dtaild milstons (Danil Lo Russo, 02/09/2014, ) A IG Complianc Audits (RSS and Childrn s Srvics) (Danil Lo Russo, A IG-ICT Scurit Assuranc rporting schdul with CSU to b agrd during Q1 115 (Danil Lo Russo, A Dvlopmnt of ntwork of Information Govrnanc Champions across CCG during Q2 (Danil Lo Russo, 01/04/2015, ) Expctd Compltion Dat Handlr 01/04/2015 Danil Lo Russo DQG - Dirctor of Qualit and Safguarding 05 - Qualit To nhanc qualit and saft, To rduc inqualitis in halth R Communit Providr capacit to undrtak brast scrning programms At th North Wst Surr CCG Clinical Qualit Rviw Mtings with main communit providr, it has bn notd that thr is not sufficint capacit to mt all th srvic spcifications for th brast scrning srvic. Th risks ar phsical/patint saft and rputation. Th k ara of dficintl is th scrning srvic for womn in th ag brackt, and not bing scrnd at th dsird frqunc Rar 2 C Clinical Qualit Rviw Mtings with Providr C Ara Tam survillanc (as part of cancr stratg) C Brast Scrning Attndnc to Clinical Qualit Rviw Mting Canclld mtings which ar not rschduld in month. Clinical Qualit Rviw Mting with providr. National monitoring through ara tam. A Intrim submission of IGT rturn for CCG (nonmandator) (Danil Lo Russo, 30/10/2014, ) 31/07/2014 Hln DGC - Dirctor of Govrnanc and Complianc 06 - Stratgic To mpowr local popl R Patint and public ngagmnt activitis - Listning to patints - do not ffctivl ngag hard to rach communitis In accordanc with qualit and divrsit: w hav t to full ngag with all our population and ar t to rach thos who ar dmd hard to rach. This is du to th divrsit btwn oung and old/ transint and working. Thr is th risk that thr will b spcific srvics that will not b providd to or accssd b spcific communit groups. Likl 16 Modr at 9 Unlikl C Capacit Rviw 4 C Halth Watch C Informal fdback from GPs, MPs, wbsit and othr qualatativ sourcs C Srious Incidnt rporting sstm C Qualit dashboard mtrics including patint complaints C Patint Engagmnt Stratg C Qualit Assuranc managr and Patint Engagmnt managr in post C Patint and Public Engagmnt via Social Mdia w do not hav a full dmographic rprsntation from our patints. Our nw stratg will look to rfrsh our approach to nsur w full ngag. W hav a procss in plac to listn to patints: PPG-PPE group to Qualit Committ W hav st up digital sstms and social mdia to nabl this: wbsit, twittr and facbook A Rviw Equalit and Divrsit stratg and objctivs (Liz Patro, A Mmbrship schm (Paul Dav, 01/04/2014, ) A Rfrsh Patint Engagmnt Stratg with Action Plan (Liz Patro, 15/09/2014, ) A Explor sstmatic captur of fdback from G&W population (Liz Patro, A Explor scop for bidding for dsignatd Hath Visitor (for travllr communit) (Liz Patro, 15/07/2014, ) 30/09/2014 Liz Patro Pag 1 of 5

2 9th Sptmbr 2014 Rsponsibl Dirctorat Natur of Risk Objctivs Risk Risk Dtail DQG - Dirctor of 05 - Qualit Organisational Qualit and xcllnc Safguarding R Car Homs and Qualit Concrns - admissions to acut Thr ar qualit concrns rlatd to possibl inappropriat admissions into th acut trust qualit, saft, rputation which ma caus patint and famil distrss Rating Rating Inhrnt Currn Currn Currn Targt Targt Targt Impact Likli Scor Impact Likli Scor Impact Likli Scor Controls Gaps in control or action rquird Assurancs Futur actions C Risk Stratification of Car Likl Modr Unlikl Homs- Car Hom Projct Groupat Safguarding Nurs-adults C Survillanc of A&E admission data and SECAMB C Intllignc from wkl BCF HIG Data rmains difficult to collct givn HRG coding and coding of patint dtails (own homs vrsus car hom dtails). Work with car homs continus Training and Dvlopmnt gapwork will nd to dvlop in this ara Hard data (BI) Soft data from A&E Working with car homs in accordanc with risk stratification and data intllignc Sightd b Dsignat Safguarding Nurs and Qualit tam A Audit of data (Hln, 30/06/2014, ) A St up car hom forum (Victoria Stobbart, 31/10/2014, ) Expctd Compltion Dat Handlr 30/11/2014 Victoria Stobbart DGC - Dirctor of Govrnanc and Complianc 05 - Qualit Organisational xcllnc R To prvnt non complianc with dadlins and Organisational nsur high qualit submissions, corporat cultur - cross cutting ownrship and dadlins for cross cutting work ownrship of nds to b strngthnd g. Stratg, corporat Oprational, Annual Rports; : FOIs, managmnt aras Complaints, Invoics, Mandator training, and complianc with Minut taking and providing covr; QIPP and dadlins information govrnanc Modr at Crtain 15 Modr at 9 Modr at Unlikl 6 C Dirctor for Govrnanc and Complianc C OD workshops C Protctd tim - 2 hourswk to addrss ths aras C OD and HR stratgis and plans Gaps in control - whthr th procss of achiving complianc with dadlins is smart and ffctiv. Cntral guidanc, including LAT, nithr timl or clar All submissions complid with GB and Committs with ovrsight Local Ara Tam Q4 assuranc lttr A Staff surv (Toni Downr, 31/08/2014, ) A Rviw rlvant policis and procdurs (Samantha Chalmrs, 31/08/2014, ) A Training nds analsis (Toni Downr, 12/09/2014, ) 01/04/2015 Elain Nwton CFO - Chif Financ Officr 02 - Financial A sustainabl halth conom R Uncrtaint Impact on ovrall running costs, and srvic around futur viabilit dlivr of CSU has advrs impact on CCG sustainabilit Modr at Likl 12 Modr at 9 0 C0448 Flxibl working C CSU liaison mting on a monthl basis C K Prformanc indicators on th contract A Clos monthl monitoring of th CSU contract through prformanc mtings (Vicki Talor, 30/06/2014, ) Karn Mckinl DGC - Dirctor of Govrnanc and Complianc 06 - Stratgic Organisational xcllnc R If w ar unabl to coordinat collctiv, Collaborativ consistnt rsponss to mdia nquiris across approach to handling Surr CCGs, thr is a risk that individuals and xtrnal mdia organisations could b implicatd bfor nquiris appropriat lgal procdings and outcoms had bn idntifid. This could rprsnt a rputational risk to th organisation and a profssional risk to our mmbrs. Thr could also b financial implications, for xampl lgal fs rquird if cass ndd to b takn to court. 12 Modr at 9 Modr at 1-Rar 3 C Qualit monitoring C Structurd tlconfrncs with partnr organisations A Draft tmplats and protocols to nsur undrstanding and consistnc (Paul Dav, 31/12/2014, ) 31/12/2014 Paul Dav Pag 2 of 5

3 9th Sptmbr 2014 Rsponsibl Dirctorat Natur of Risk Objctivs Risk Risk Dtail DOCC - Dirctor 05 - Qualit To mpowr local popl R Potntial significant chang to childrn's rspit srvic (Bchs) Thr is a high lvl of srvic usr concrn about potntial closur. Risk around clarit of consultation and govrnanc arrangmnts for dcision making accross 6 CCGs. Rating Rating Inhrnt Currn Currn Currn Targt Targt Targt Impact Likli Scor Impact Likli Scor Impact Likli Scor Controls Gaps in control or action rquird Assurancs Futur actions 9 Lgal advic to b considrd in Sking xtrnal advic on futur procss 12 Modr at 6 C Rang of stakholdr mtings hav takn plac jointl with SCC C Public consultation A Indpndnt assssmnt of stakholdr rsponss to widr short brak rviw including Bchs (Du Jun 2014) (Sarah Parkr, 31/07/2014, ) A Collaborativ forum updat du Jul 2014 (Sarah Parkr, 29/08/2014, ) Expctd Compltion Dat Handlr Sarah Parkr DQG - Dirctor of Qualit and Safguarding 05 - Qualit To nhanc qualit and saft R Incrasing prvlanc of prssur damag across whol halth conom It has bn notd across Surr and Sussx CCGs that th prvalanc of avoidabl prssur damag has incrasd. Particularl for grad 2, 3 and 4. Th incras has bn notd in all sctors of th halth and social car conom. Thr ar diffrnt risks dpndnt on our position within th conom. For th CCG, th risk is rputational. Modr at Likl 12 Modr at 9 Unlikl 4 C Prssur Damag Campaign Co-ordinatd b Surr and Sussx Ara Tam C Prformanc managmnt through Clinical Qualit Rviw Mtings C Prsssur Damag Confrnc Whol halth conom risk and ffctivlnss of intgratd working Rgular survillanc and discussion at Ara Tam through th Prssur Campaign Rgular survillanc and discussion at Clinical Qualit Rviw Mtings with Providrs Rgular survillanc b Car Qualit Commission A Prssur damag workshop (Victoria Stobbart, 31/12/2014, ) 31/03/2015 Hln DQG - Dirctor of Qualit and Safguarding 05 - Qualit To nhanc qualit and saft R Qualit Issus with th Earl Prgnanc Unit at acut providr 4/6/2014: As a rsult of a srious untoward incidnt, th qualit and saft of th arl prgnanc unit, particularl out of hours, is qustionabl. Dspit a robust action plan bing dvlopd b th Trust as a rsult of th incidnt, th Commissionrs nd to rviw th srvic to nsur it is robust and good qualit for th futur. 12 Modr at 9 1- Ngligi bl 1-Rar 1 C Action Plan Following Srious Untoward Incidnt C Rviw of Incidnt and Srious Incidnt Rporting Low lvls of incidnt rporting at trust Rport on progrss of rnw of EPU A R-shaping th Earl Prganc Unit Srvic through (Sarah Casmor, 28/11/2014, ) A SI Action plan (Hln, 01/04/2015, ) 01/04/2015 Hln DOCC - Dirctor 04 - Programm Dlivr To rduc inqualitis in halth R Inqualit of uptak widns gaps - public halth Encouragmnt to incras phsical activit/rduc alcohol consumption/giv up smoking is adoptd b thos in lss dprivd aras incrasing th gap in inqualit (programm dlivr) Modr at 9 Modr at 9 0 C Monitoring uptak of initiativs. C Coordinatd action b Halth Guildford Group Halth and wll-bing board not stablishd Monitoring of intrvntions A Links to public halth rportd to th local halth and analsis tam (Vick Evans, wll-bing board. 23/08/2013, ) 05/07/2013 Joanna Barkr C Wavrl Communitis Halth and Social Inclusion group C Halth and wll-bing board DQG - Dirctor of Qualit and Safguarding 04 - Programm Dlivr Organisational xcllnc R Effctiv primar car liaison (IG and clincial incidnts) W might not b sightd on qualit issus in primar car, Givn th challngs facd b th Ara Tam of NHS England. If w ar unabl to support to mmbr practics on liv IG issus or srious clincial incidnts thn ths problms ma intrfr with our abilit to provid GP IT srvic and othr support and ma also advrsl affct our rlations with mmbr practics. Modr at 9 Modr at 9 0 C Informal support from CCG staff C Priamar Car Saft Champions C Primar Car training plan (AT) C Qualit Survillanc Group - intrnall (local) and rgionall (xtrnal) No confirmd guidanc from LAT. CQC monitoring NHS England A Primar Car training plan (AT) (Samantha Chalmrs, 01/08/2014, ) A Informal practic visit (Samantha Chalmrs, 29/08/2014, ) A Invstigat possibilit of SI rporting to b managd via GP confdration (Samantha Chalmrs, 01/09/2014, ) 31/08/2014 Lah Moss Pag 3 of 5

4 9th Sptmbr 2014 Rsponsibl Dirctorat Natur of Risk Objctivs Risk Risk Dtail DGC - Dirctor of 01 - Complianc Organisational Govrnanc and xcllnc Complianc R Emrgnc Prpardnss and Rsilinc Rspons arrangmnts - Complianc with th rquirmnts of th Civil Contingncis Act If th EPRR arrangmnts ar not in plac thn th organisation will not mt its statutor rquirmnts undr th CCA as a Cat2 rspondr. Knowldg of th Cat2 rquirmnts of a CCG is limitd and dos not rflct th formr arrangmnts usd b th PCT. An incomplt undrstanding of th EPRR rquirmnts ma lad to incomplt or inappropriat plans to b put in plac b th CCG, or incomplt or inappropriat xpctations mad b th providr organisations during a Incidnt. Rating Rating Inhrnt Currn Currn Currn Targt Targt Targt Impact Likli Scor Impact Likli Scor Impact Likli Scor Controls Gaps in control or action rquird Assurancs Futur actions C Attndanc at th LHRP Awaiting furthr guidanc for forum and oprational group mting som aspcts from LAT. Crtain Unlikl Unlikl C On-call rota and protocol C Emrgnc Prparnss and Rsillianc Rspons Plan and Polic C Cascad sstms for EPRR alrts to car homs and GPs C Compltion of surg and scalation plan b urgnt car board Extrnal monitoring b LAT for complianc via vidnc basd assssmnts. A Individualisd larning for on-call managrs r organisational capabilitis (Samantha Chalmrs, 31/08/2014, ) A Exrcis tsting Fb 15 (Samantha Chalmrs, 30/04/2015, ) A Link in with acut providr 'pag on' sstm for oncall managrs (Samantha Chalmrs, 31/08/2014, ) Expctd Compltion Dat Handlr 30/04/2015 Samantha Chalmrs C Slf assssmnt assuranc against th EPRR framwork C NHS England Assuranc Framwork A Draft pandmic flu plan (Samantha Chalmrs, 29/08/2014, ) DGC - Dirctor of Govrnanc and Complianc DQG - Dirctor of Qualit and Safguarding 07 - Transition Organisational xcllnc 05 - Qualit To nhanc qualit and saft R If w do not put in plac a suitabl sstm and Govrnanc and polic control, including FOI's and procss to rviw and adopt clinical and corporat govrnanc policis and procdurs thn th CCG falls short of xpctd lgistlativ Complaints falls short standards of govrnanc. (Complianc, of xpctd rputation) standards R Qualit of Srvic Providd b Acut Trust Not Mting Commissionr Expctations Patints who rciv tratmnt at an acut trust ma xprinc sub-optimal qualit of srvic on saft, clinical ffctivnss and gnral xprinc. This could rsult in xtndd lngth of sta, radmission, incrasd risk of mortalit, pschological trauma, additional tratmnts originall not rquird. It ma also rsult in G&WCCG bing prcivd at not mting thir commissioning intntions, possibl bringing th organisation into disriput. Catastr ophic Likl Crtain Modr at Unlikl Unlikl 8 6 Unlikl 4 C Organisational Dvlopmnt Plan rfrsh C CCG Constitution. C PPG and Patint Engagmnt Stratg. C Polic for policis 1-Rar 2 C Had of Qualit Assuranc in post C Prformanc managmnt C Sharing of qualit intllignc with othr k stakholdrs C Sourcing othr halthcar providrs for various srvics Capacit within tams ma hindr progrss. No rolling forward plan for rviw/audit Informal mtings rquird to dvlop working rlationship. Wkl on-sit inspctions to b instigatd. Wkl rports around prfomanc against infction control targts. All Dirctors own polic implmntation Intrnal Audit LAT Q4 assuranc lttr Concrns ar bing adrssd via formal rsolution procss and contract managmnt. Monthl rports to idntif improvmnts. A H&S support from CSU for ssntial policis (Samantha Chalmrs,, ) A Complianc audit (Danil Lo Russo, 31/10/2014, ) A CCG is an activ mmbr of th H&WBB (Elain Nwton,, ) 01/04/2015 Danil Lo Russo 30/09/2014 Hln DQG - Dirctor of Qualit and Safguarding DGC - Dirctor of Govrnanc and Complianc 05 - Qualit To nhanc qualit and saft 04 - Programm Dlivr To rduc inqualitis in halth R Qualit and A largr proportion of srious incidnts that timlinss of Srious occurd at a Commissiond srvic - acut Incidnt providr hav not bn submittd for closur invstigations, within th NHS England spcifid timscals. rporting and closur Th dla poss a patint saft and rputational risk. In addition, thr ar associatd risks with th nwl stablishd SI sub-committ in particular, th ar as follows: R Frinds and Famil Tst If th Frinds and Famil Tst is discontinud post-pilot thr could b rputational damag to th CCG rgarding appropriat xpnditur of rsourcs. If th Frinds and Famil Tst is continud and fails to dlivr maningful data, thr could b also b rputational damag to th CCG. Likl 12 Modr at 8 Unlikl 6 1- Ngligi bl 6 C Notification of concrns to 1-Rar 1 rlvant C rgulators Srious Incidnt (HSE-CQC) Closur Plan Unlikl C Clinical Qualit Rviw Mtings C Dputis to attnd mtings to prvnt dlas du to non quorat mtings. 4 C Wkl Softwar vrsion rlas updats Larning vnts accross surr to b stablishd. Slction of providr did not follow rccomndd procdurs Monthl srious incidnt subcommitt Monthl srious incidnt papr Qualit controll procss prior to submission for closur NHSE final approval of C2 incidnts NHSE ovrsight Obsrvator analtical tam ovrsight A Production of Srious Incidnt Closur Plan (Hln, 30/04/2014, ) A Liaison with Ara Tam for Grad 2 Closurs (, 30/06/2014, ) A Larning vnts (Hln A QES FFT sstm prsntations (Liz Patro, 30/09/2015 Hln 30/09/2014 Liz Patro CFO - Chif Financ Officr 02 - Financial A sustainabl halth conom R Contract sign off Sign off of all acut contracts within th ovrall CCG cash nvlop, Unagrd contracts could rsult in furthr cost prssurs Modr at 9 Unlikl 4 Unlikl 4 C Contract managr in post C Wkl rporting Non NHS England ovrsight Monitor A Agr shard timtabl for 116 plan (Niki Bair, 31/12/2014, ) 30/04/2015 Niki Bair Pag 4 of 5

5 9th Sptmbr 2014 Rsponsibl Dirctorat Natur of Risk Objctivs Risk Risk Dtail DOCC - Dirctor 05 - Qualit To rduc inqualitis in halth R Th dlivr of PHBs that dmonstrats th parit of srvics availabl across rgions If w can't dmonstrat that w hav takn into considration th rang of srvics covrd b othr gographic rgions and manag patint/carr xpctations, thn thr ma b financial consqus (appals), rputational risk of poor publicit and failur of our statutor dut for qualit, accssabilit and mting th halth nds of th population. Rating Rating Inhrnt Currn Currn Currn Targt Targt Impact Likli Scor Impact Likli Scor Impact Likli Modr Likl Ngligi Ngligi Likl at bl bl Targt Scor Controls Gaps in control or action rquird Assurancs Futur actions 4 C Collaborativ arrangmnts No assuranc for spcialist with othr CCGs srvics and univrsal HCB C Stakholdr ngagmnt vnts C Rgular rports to CCG collaborativs and Childrns Halth and Wllbing Board Survilanc b Surr count council using appals procss for Educaltion Halthcar Plans A Working group with Surr Count Council, Educaltion, Famil Voic r publicising th changs (Dian Mccormack, A Publish information on childrn's sction of wbsit (Dian Mccormack, Expctd Compltion Dat Handlr 30/09/2014 Dian Mccormack C SEN nw lgislation work A Mting with NHS Pag 5 of 5