Annual Report and Accounts - The Great Western Hospital

Risk
Licence to operate
(compliance with
CQC registration
and regulatory
regime)
Actions to manage and mitigate, including how outcomes will be
assessed
• Plans implemented to address CQC compliance concerns, CQC notified with reinspection
by CQC outstanding
• Programme of matron led CQC style visits to review practise, and staff response
• Periodic Clinical Audit compliance reviews, with outcomes and action plans where
required being presented and scrutinised by Governance Committee, providing
assurance to the Board.
• CQC compliance included in annual internal audit plan. The audit
report/compliance being reported to both the Governance Committee and Audit
Risk & Assurance Committee. Actions plans to resolve compliance issues will be
presented and scrutinised by the Governance Committee.
• Monthly reporting on compliance
Financial and
reputation risk if non
achievement of
NHSLA level 2 –
Acute standards in
November 2012 and
Maternity in May
2013
• Gap analysis completed and action plan in place,
• Monitored monthly via Executive Committee and Patient Safety and Quality Group.
• Informal Assessments completed by NHSLA prior to formal assessment with
action plans updated to reflect outcome.
• Included in work plan for Parkhill, Internal Auditors with out-come being presented
to Audit Risk & Assurance Committee
• Scrutiny of plans by the Governance Committee.
• Clinical Governance Committee and Audit, Risk & Assurance Committee will
provides assurance to Trust Board.
QIPP/Savings
delivery, target is
£16m which is 5.7%
of turnover. Non
delivery leading to a
deficit, poor liquidity
and reduction in
Financial Risk
Rating
• Programme Management Arrangements in place, including increased support to
the Directorates
• Clinical engagement and increased partnership working with other providers.
• Targets included in Directorate Accountability Agreements implemented as part of
the new performance management arrangements
• Delivery monitored monthly via Directorate Performance meetings and Executive
Committee.
• Scrutiny of plans by the Finance & Investment Committee
• External review of plans by Parkhill, these will take place in at end of quarter 1 and
in quarter 3. Outcomes presented to Finance & Investment Committee and Audit
Risk & Assurance Committee, with issues escalated to the Board
• Multi-provider governance arrangements in place for delivery of QIPP, with
representation Executive Directors and Associate Medical Directors of the Trust,
reporting into the Community Change Programme Groups (QIPP)
• Increase working capital facility, tender planned for August with new agreement in
place by 1 st December 2012
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