Agenda Item: 12 Enclosure: CKWCB/13/20 DATE OF MEETING: 22nd January 2013
Category of Paper Tick()
Paper Title: Board Assurance Framework
Decision and Approval Position statement
Responsible Director:
Discussion
√
Information
√
Terry Service Paper Author: Gill Galdins
FOI Status: Open
Executive Summary:
This report is to update the Board on the Board Assurance Framework The Board Assurance Framework (BAF) is a strategic governance tool designed to provide assurances to board that appropriate risk and governance arrangements are in place and effective in achieving organisational objectives and controlling the impact of identified risks.
Outcome of Equality Impact Assessment: Sub Group/Committee: Recommendation (s):
Page 1 of 53
N/A
Governance Committee That the board receives and notes the content of the report.
1.0
Purpose of Report 1.1
2.0
Background 2.1
3.0
4.0
To provide the Board Assurance Framework for review to Board as an accurate and effective record of the governance and risk management arrangements for the CKW cluster.
The Board Assurance Framework (BAF – Appendix A) is a strategic governance tool designed to provide assurances to board that appropriate risk and governance arrangements are in place and effective in achieving organisational objectives and controlling the impact of identified risks.
Review process 3.1
Confirmation was received that all risk owners have been correctly identified.
3.2
The BAF has been circulated to Leads and risk owners to update each entry with responses collated into one document.
3.3
The BAF has been formally reviewed by CLT and the Governance Committee on 23.11.12 and the Audit Committee on 27 November 2012 with all recommendations completed and included within the attached framework.
Recommendations 4.1 Receive this report
Page 2 of 53
Jan 2013 1 Strategic Objective
Board Reports
Continuously improve the quality of commissioned health services (Effectiveness, Safety and Experience) Executive Director Lead; Sue Cannon Executive Director for Quality and Governance
Principal Risks RAG
Key Controls
Risk Owner
1.1) Implementation of cost improvement programmes has an adverse impact on the quality of services and patient safety.
Risk Owner: Sue Cannon
Risk Manager (s) Matt Walsh
Amb er
All Cost Improvement Schemes to be reviewed for quality impact by Medical Directors and Directors of Nursing.
Scrutiny and review of service specifications, delegated responsibility through terms of reference to CCEs.
Assurances on Controls
Transition report to Board. Quality reports to CCEs and Quality Boards. Audit and Governance Group report through CCE Governance Committee oversight of quality reporting
Key Positive Assurance
Corrective Action (**External / Independent)
Significant Calderdale CCG Authorisation Moderation th Final Report (25 Oct 2012) confirmed Good governance arrangements in place.
Calderdale CCG rated green on all aspects of quality.
Wakefield CCG Authorisation Moderation th Final Report (25 Oct 2012) confirmed Good governance arrangements in place.
CCGs initial SHA rating Scrutiny and review through Clinical Quality / Contract Management Boards
Carol McKenna Scrutiny and review
Internal audit of governance arrangements CCG authorisation
Gaps in Control (GIC) and/or
Wakefield CCG rated green on all aspects of quality except two criteria regarding complaints and safeguarding
Gaps in Assurance (GIA) (GIC) Key controls are not fully embedded across all CCGs.
(GIA) No Quality Impact assessment has yet been received by CCGs in relation to the pending Outline Business Case
A task and finish group has been set up to design the processes to support the creation of the quality impact assessment.
Responsib ility Target Date th
26 November 2012
An Executive Group is planned to scrutinise the completed Quality Impact Assessment in November 2012
Wakefield CCG action plan in place including updating patient leaflet and website
Greater Huddersfield CCG Moderation rd Report (3 December 2012) confirmed
3
through Transformation / QIPP governance
Chris Dowse Jo Webster
process
Participation in Board to Board reviews.
Good governance arrangements in place and rated green on all aspects of quality.
Wakefield Safeguarding policy ratified by CCE.
NKCCG Authorisation Panel date is on the th 12 of December.
The West Yorkshire Audit Consortium have reviewed the Quality Governance arrangements of all 4 CCGs in November and found significant assurance on the controls Reasonable Limited
1 Strategic Objective
Board Reports
Continuously improve the quality of commissioned health services (Effectiveness, Safety and Experience) Executive Director Lead; Sue Cannon Executive Director for Quality and Governance
Principal Risks RAG
Key Controls
Risk Owner
1.2) Patients are
Amb
Triangulation of Quality
Gaps in Control (GIC) and/or
Assurances on Controls
Key Positive Assurance (**External / Independent)
Gaps in Assurance (GIA)
Quality
Significant
(GIC)
Corrective Action
Responsi bility Target Date
Risk summit held with
4
not receiving the expected standards of care through providers not adhering to the standards set by commissioners.
er
information from a range of services such as Incidents, PALS, Complaints, CQC QRPs,
Risk Manager (s) Matt Walsh Carol McKenna Chris Dowse Jo Webster
Key controls are not fully embedded across all CCGs
CQC Inspection reports Safeguarding reports CQC – Quarterly risk profiles
Patient feedback National / regional reviews/ audit -
Risk Owner: Sue Cannon
Dashboard report and exceptions to Quality Group and CCE’s
th
Board Quality reports
Calderdale CCG Moderation Report (25 Oct 2012) confirmed Good governance arrangements in place and rated green on all aspects of quality.
One provider has had warning/compliance notices issues by the CQC.
the provider, SHA, CQC and commissioners.
Subsequent Quality Summit led by the CCG’s.
CQUINS
Policies & procedures to support such as risk management, whistleblowing and safeguarding
Quality governance arrangements in place Board, Governance committee, CCEs/Quality Groups, Contract Quality Boards
Governance Committee scrutiny
Internal audit review of governance arrangements
th
Wakefield CCG Moderation Report (25 Oct 2012) confirmed Good governance arrangements in place and rated green on all aspects of quality,
Internal audit not yet undertaken.
except two criteria regarding complaints and safeguarding
Greater Huddersfield CCG Moderation Report (3 December 2012) confirmed Good governance arrangements in place and rated green on all aspects of quality.
(GIA)
rd
North Kirklees has its Site authorisation panel day th on the 12 of December 2012
Wakefield escalation process in place for dealing with issues relating to MYHT. This includes a risk summit and quality summit which were both held n October. In addition the CCG is developing monthly commissioner quality inspection visits at MYHT
The West Yorkshire Audit Consortium tested the quality governance arrangements, in November in each of the 4 CCGs and found significant assurance on the control measures in each CCG
5
Reasonable Limited
1 Strategic Objective
Board Reports
Continuously improve the quality of commissioned health services (Effectiveness, Safety and Experience) Executive Director Lead; Sue Cannon Executive Director for Quality and Governance Principal Risks Key Controls Risk Owner
RAG
1. 3) Constituent PCT controls become ineffective during a transition period e.g. safeguarding, performance management of serious incidents, handling patient complaints, disseminating safety alerts, etc.
Amb er
Risk Owner: Sue
Incident management system in place.
Safety alert process.
Documented policies and procedures in place to support such as safeguarding, serious incidents, risk management and triangulation. Continue to review and monitor these.
Assurances on Controls
Quality reports to CCE & CQBs on key performance indicators and escalation
Key Positive Assurance
Gaps in Control (GIC) and/or
(**External / Independent)
Gaps in Assurance (GIA)
Corrective Action
Significant
(GIC)
CQC Inspection reports KSAB has held a challenge event with all providers including NHS Kirklees in September 2012.
Key controls are not fully embedded across all CCGs
Wakefield CCG Moderation th Report (25 Oct 2012) confirmed Good governance arrangements in place and rated green on all aspects of quality.
(GIA)
Responsib ility Target Date
Options appraisal underway to be considered by GHCCG, North Kirklees CCG and Calderdale CCG during December 2012
Board Quality reports
Annual review and selfassessment of governance arrangements
Quality governance Quarterly
except two criteria regarding complaints and safeguarding
Adult safeguarding resource need to be increased.
Quality handover Document continues to progress as per SHA timelines.
Quality Handover Document will not complete until March 2013
6
1 Strategic Objective
Board Reports
Continuously improve the quality of commissioned health services (Effectiveness, Safety and Experience) Executive Director Lead; Sue Cannon Executive Director for Quality and Governance Principal Risks Key Controls Risk Owner
RAG
Cannon
arrangements in place
Risk Manager (
Board, Governance committee, CCEs/Quality Groups, Contract Quality Boards, LSCB & LSAB
Matt Walsh Carol McKenna Chris Dowse
CCG Leadership in place
Jo Webster Annual work plan for key safety priorities
Quality representation on the PCT Close Down Steering Group
Assurances on Controls
reporting to the SHA on safeguarding compliance activity.
Key Positive Assurance
Gaps in Control (GIC) and/or
(**External / Independent)
Gaps in Assurance (GIA)
Corrective Action
Responsib ility Target Date
Quality Handover Document processes continues as per SHA timelines and overseen by the Cluster Governance Committee. Reasonable Internal audit and risk management report – Calderdale NHS Kirklees has undertaken a gap analysis against the interim safeguarding framework issued by the NCB in Sept 2012. Limited
7
1 Strategic Objective
Board Reports
Continuously improve the quality of commissioned health services (Effectiveness, Safety and Experience) Executive Director Lead; Sue Cannon Executive Director for Quality and Governance Principal Risks Key Controls Risk Owner
RAG
1.4) Clinical Commissioning Groups are not prepared and supported to take on their future roles with respect to quality
Amb er
Risk Owner: Sue Cannon
Risk Manager (s) Matt Walsh
Quality CCG leadership identified
OD plan in place for each CCG ; which incorporates three domains of Quality
Delegation for responsibility for Quality CCG (PCT) via CCE Terms of Reference
Quality Group established for each CCG
Assurances on Controls
Regular reports to CCE on implementation of OD plan including Quality developments
CCG Self assessment completed and participation in Board to Board reviews
Transition report to Board
Key Positive Assurance (**External / Independent) Significant Internal audit plan includes Quality Plan
Wakefield CCG Moderation Report th (25 Oct 2012) confirmed Good governance arrangements in place and rated green on all aspects of quality.
Chris Dowse Jo Webster
GP leadership on Quality Boards
Corrective Action
Gaps in Assurance (GIA) (GIC)
None identified
Calderdale CCG Moderation Report th (25 Oct 2012) confirmed Good arrangements in place and rated green on all aspects of quality
Responsib ility Target Date
Quality Groups are fully embedded in the governance structure. West Yorkshire Audit Consortium reviewed the Quality Governance mechanisms for each of the 4 CCGs and judged that there was significant assurance on the controls for all CCGs
(GIA)
except two criteria regarding complaints and safeguarding
Carol McKenna Final recommendation from NHSCB on CCG authorisation
Gaps in Control (GIC) and/or
Greater Huddersfield CCG rd Moderation Report (3 December 2012) confirmed Good governance arrangements in place and rated
Movement of staff as part of the matching and pooling processes may negatively affect the command and control of the quality
8
green on all aspects of quality. NHSCB led authorisation process which will test preparedness in respect to quality
agenda
NKCCG Authorisation Panel date is th on the 12 of December. Reasonable
Limited
9
1 Strategic Objective
Board Reports
Continuously improve the quality of commissioned health services (Effectiveness, Safety and Experience) Executive Director Lead; Sue Cannon Executive Director for Quality and Governance Principal Risks Key Controls Risk Owner
RAG
1.5) During transition there is a deterioration in the patient experience of health services
Amb er
Risk Owner: Sue Cannon
Risk Manager (s)
There is a variety of information received by the CCGs regarding patient experience this includes:-
National patient survey Real time feedback Complaints Feedback from Links CQUINS Delegation through terms of reference to CCE’s, CCG Quality Groups established.
Matt Walsh Carol McKenna
Quality reporting to CCEs including key performance indicators and escalation
Board Quality report
Internal audit review of governance arrangements
Dr Foster reports Quality and Risk summits in place to monitor improvements at MYHT
Gaps in Control (GIC) and/or
Key Positive Assurance (**External / Independent)
Gaps in Assurance (GIA)
Significant
Scrutiny review through Clinical Quality Boards
Chris Dowse Jo Webster
Assurances on Controls
(GIC)
All providers submitted readiness declarations in terms of friends and family test.
Calderdale CCG Moderation Report (25 Oct 2012) rated green on all aspects of quality.
Corrective Action
Responsib ility Target Date
Key control are not yet fully embedded across CCGs th
(GIA) Wakefield CCG Authorisation Moderation th Final Report (25 Oct 2012) confirmed Good governance arrangements in place.
Internal audit best practice guidance is not yet fully implemented.
Wakefield CCG rated green on all aspects of quality except two criteria regarding complaints and
Greater Huddersfield CCG Moderation rd Report (3 December 2012) confirmed Good governance arrangements in place
10
and rated green on all aspects of quality.
NKCCG Authorisation Panel date is on the th 12 of December. Reasonable HSMR rates improving and performance at MYHT is improving
Limited
2 Strategic Objective
Board Reports
Sustain the Integrated Finance, Operations and Delivery System Executive Director Lead; Ian Currell Executive Director of Finance and Efficiency – Update provided by Ian Currell on 03/12/2012 Principal Risks Key Controls Risk Owner 2.1) Fail to
RAG Red
Financial budgets, QIPP,
Assurances on Controls
Monthly
Key Positive Assurance
Gaps in Control (GIC) and/or
(**External / Independent)
Gaps in Assurance (GIA)
Corrective Action
Significant
GIC
Responsib ility Target Date
The Cluster Chief Executive and
11
maintain financial control and service performance with constituent PCTs.
Risk Owner: Ian Currell
Risk Manager (s) Matt Walsh Carol McKenna Chris Dowse Jo Webster Julie Lawreniuk Steve Brennan Jim Hayburn
activity and other key targets agreed for each PCT by the Board for 2012/13. Financial and performance reporting is included in the terms of reference of the Board, CCE’s and Finance and Performance Groups. Responsibility and accountability for financial and other performance targets is set out in individual directors Objectives. Annual Internal Audit Plan agreed by the Audit Committee is being implemented to ensure an independent check that key controls and systems are in place. The financial results for the year are subject to review and by the External Auditors who report back to the Audit Committee.
reporting on the financial position, including QIPP, by PCT. These reports are reported to and reviewed at
Calderdale CCG th Moderation Report (25 Oct 2012) rated green on all aspects of financial controls and performancemanagement arrangements.
MYHT are reporting an in year deficit of £26m. As at December 2012 they are reporting that their ytd position is better than plan.
1 Finance and Performance Groups
Wakefield CCG Moderation th Report (25 Oct 2012) rated green on all aspects of financial controls and performancemanagement arrangements.
GIA
2 CCE’s 3 Executive Team meetings 4 Public Board Meetings (Bi monthly) 5 SHA level on behalf of the DH
Greater Huddersfield CCG moderation report rated greed on all aspects of financial controls and performance management arrangements.
North Kirklees CCG yet to undergo their authorisation assessment.
Director of Finance are working closely with the Trust and the SHA to clarify the size of the challenge and develop plans to address the significant financial gap.
These outline options should be available for internal review at the end of the first quarter 2012/13
Cluster DoF
End Q4 2012.13
The Board will continue to be kept informed on a regular basis. It is recognised that there will be a challenge for the relevant CCG’s managing this situation as the new Commissioning arrangements come into place.
Reasonable Annual audit of accounts
Cluster Boards and CCG’s receive regular financial reports on MYHT Limited
12
2 Strategic Objective
Board Reports
Sustain the Integrated Finance, Operations and Delivery System Executive Director Lead; Ian Currell Executive Director of Finance and Efficiency - Update provided by Ian Currell on 03/12/2012 Key Positive Assurance
Principal Risks Key Controls Risk Owner
RAG
2.2)Lack of effective systems in place to manage devolved budgets.
Amb er
Scheme of delegation to CCG’s agreed at October and December 2011 Cluster Board meetings
Budgets allocated to and reported on, at CCG level, in 2011/12 and 12/13 Risk Owner: Ian Currell
Risk Manager (s) Matt Walsh
Monitoring of financial performance by CCG’s is part of the formal governance arrangements, including Finance and Performance groups and the CCE’s.
Assurances on Controls
Finance report to the Board
Performance against CCG budgets will be monitored by the Finance and Performance Groups on a monthly basis.
Jo Webster Julie Lawreniuk
The Cluster Director of Finance retains overall accountability for financial management during the transition period.
Significant
The Cluster Director of Finance ensures robust performance management processes are in place at CCG level and retains an overview of performance across the cluster.
Internal Audit reviews will be reported to the Audit Committee/s CCG authorisation process
GIC Reasonable Monthly CCE’s and Finance and Performance groups Limited
Corrective Action
Gaps in Assurance (GIA)
Not fully implemented.
Carol McKenna Chris Dowse
(**External / Independent)
Gaps in Control (GIC) and/or
No chief finance officer for Wakefield
Wakefield seen as a high level risk in terms of meeting its financial targets due to the gap and potential risk as the CCG has the lowest margin of financial flexibility and the most exposure to MYHT
There are revised management and governance arrangements in place that have been approved by the Cluster Board for managing financial and operational performance and ensuring that systems and processes are robust. These arrangements include monthly CCE and Finance and Performance sub group meetings where detailed performance reports are reviewed, under performance identified and then followed up.
Responsib ility Target Date
End July 12
Designate Chief Officers have been assigned to the CCGs. Designate Chief Finance Officers have been assigned, a shared post for
13
The CCG structure includes an Accountable Officer and a Senior Financial Officer who will be accountable for the financial performance of the CCG including ensuring that all the financial targets are met.
Steve Brennan Jim Hayburn
Calderdale and Greater Huddersfield and one person covering North Kirklees. This leaves a gap in Wakefield.
Self-Assessment Board to Boards
The annual internal audit plan will include the formal review of CCG financial management.
CCG OD plans include financial management and financial Governance
2 Strategic Objective
Board Reports
Sustain the Integrated Finance, Operations and Delivery System Executive Director Lead; Ian Currell Interim Executive Director of Finance and Efficiency - Update provided by Ian Currell on 03/12/2012
Principal Risks Risk Owner
Risk Statu s
Key Controls
Assurances on Controls
Key Positive Assurance
Gaps in Control (GIC) and/or
(**External / Independent)
Gaps in Assurance (GIA)
Corrective Action
Responsib ility Target Date
RAG 2.3) QIPP challenge not met due to the lack of realistic QIPP plans from PCT /
Amb er
3 Year QIPP plan has been submitted to SHA. Annual Operating Plans for 2012/13 included the QIPP. plans – these were reviewed and agreed by
PCT QIPP Plans in place to 2014/15
Monthly finance reports detail
Significant Calderdale CCG Moderation Report (25th Oct 2012) confirmed Good strategic Plan and QIPP plans in place
(GIC)
(GIA)
CFO’s Committee established to review effectiveness of primary care transformation scheme in Wakefield to
January 2013
14
CCGs and /or poor monitoring and delivery of the agreed plan.
Risk Owner: Ian Currell
Risk Manager (s) Matt Walsh Carol McKenna Chris Dowse Jo Webster Julie Lawreniuk Steve Brennan Jim Hayburn
the PCT Boards QIPP plans relating to healthcare contracts are built into annual SLA’s.
main schemes and performance against these.
Under the new Governance arrangements QIPP proposals and performance against approved schemes are reviewed monthly by the relevant CCE Finance and Performance Group.
Monthly SMT and Finance and Performance Group Monitoring of QIPP schemes.
Contracts have been agreed within tight margins reducing the acute QIPP risk for 2012/13. If these are not achieved in 2012/13 then this will present a financial risk for the starting contract value for the following year
Quarterly DH/SHA monitoring.
Reasonable reported Monthly to and reviewed by the CCE’s and Finance and Performance Groups
reduce NEL activity. Some shortfall in plans during 2012/13. In particular rise in NEL activity in Wakefield has caused concern.
Where there are shortfalls in QIPP schemes budget contingencies are available in 2012/13.
Cluster Senior Finance team for Financial and QIPP made up of members from the 3 PCT’s that meet on a regular basis which gives a view across the cluster
Limited
Board reporting
CCE reporting supported by CCG level detailed QIPP monitoring
15
3 Strategic Objective
Board Reports
Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer
Principal Risks Risk Owner
3.1) Major transformationa l programmes are not delivered across the commissioning economy.
Risk Status
Key Positive Assurance Key Controls
RAG Amber
Calderdale and Huddersfield
Programme Board established with membership from the 7 partners.
Steering group established Risk Owner: Mike Potts
Well established PM methodology in place supported by PMO.
Risk Manager (s) Carol McKenna Matt Walsh Jo Webster
Assurances on Controls
Programme in place setting out vision and objectives.
Programme Board reports through DCO to CCE
(**External / Independent) Significant
MYHT Reports to Cluster Board and Exec team
MY HEFT update reports to MY HEFT Board and Cluster Board, regularly. Updates to MYHT Board
Corrective Action Gaps in Assurance (GIA) (GIA)
Informal DH gateway review report (Oct 2012)
Reliance on National evidence.
Evidence within CB moderation report for th Calderdale (25 Oct 2012)
Detail on major reconfiguration across the whole health economy still at early stages
Regular updates to Cluster Board.
Minutes of Board meetings; minutes of steering group; outputs from whole systems events; developing business cases from care streams
Gaps in Control (GIC) and/or
Garland review of MYHT
Tri partite Formal Agreement MYHT
SCAP and NCAT processes underway to quality assure the OBC at MYHT.
Scope for major reconfiguration may be limited
Reasonable
Finance colleagues from 7 partner organisations working to produce clear financial picture for whole system by end Dec 2012..
Ongoing Clinical commissioning Groups priorities aligned with whole health economy strategy.
Responsibili ty Target Date
SCAP/NCAT quality assurance processes to be completed by February 2012. Jo Webster lead
Priorities agreed with Health and Well Being Boards x 3
High level risk
16
Chris Dowse
Clinical leadership at CCG fully committed
MYHT Programme Office in place with key performance indicator agreed and monitored for elements of the programme.
(GIC) QIPP outcome report sent to HEFT Executive group, Cluster CE, Cluster DoF, Wakefield District and Kirklees COOs, MYHT DoF and Dir Strategy Dec 2011 for action.
(GIA) Limited MYHEFT high level risk register
Report on CCGs’ commissioning intentions provided to MYHT and Cluster senior team.
register required for CHFT
Further investment and support from PMO in Wakefield
No CHFT RR
QIPP tracker and oversight
Mid Yorks HEFT Programme set up overseen by Programme Management Office, lead by Programme Director
MY HEFT PMO review of relevant 12/13 QIPP schemes.
Whole System Transformation event and report on priorities widely circulated for action
Regular meetings between CCG GPs and MYHT clinicians to work through Clinical Service Strategy options.
MY HEFT PMO survey of CCGs’ potential commissioning intentions
Review of MYHT CIPs by Ernst Young
Analysis of outputs from above
17
two activities by PMO
18
3 Strategic Objective
Board Reports
Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer
Principal Risks Risk Owner
Risk Statu s
Key Controls
Assurances on Controls
Key Positive Assurance
Gaps in Control (GIC) and/or
(**External / Independent)
Gaps in Assurance (GIA)
Corrective Action
RAG 3.2) Safe and secure transfer of responsibilities from PCTs to new organisations does not occur
Amb er
Governance Committee Terms of Reference revised September 2012 with specific remit for handover and closedown
Significant (GIC)
Governance Committee
Nationally a number of unallocated functions
Audit Committee Quality Legacy report submitted to SHA October 2012
Risk Owner: Mike Potts
Risk Manager (s)
Scrutiny & oversight by
Responsib ility Target Date
Transition Steering Group meeting monthly with leads for all areas, reports to Governance Committee
Gill Galdins Legal advice secured to support transition and ensure safe transfer.
Receiver Workshops being
Reasonable Management oversight by executive team
Monthly tracker assurance report completed for SHA with RAG rating of risks – mainly amber / green
(GIA)
Review of quality legacy report from SHA awaited
Limited Attend monthly North of England Governance Transition meeting
Advice still expected on some liability transfers r.eg. NHSLA
Performance management quarterly by North of England
19
held mid November 2012 on transition Standing agenda item on Board committees regarding items for inclusion in legacy documents.
SHA
Internal Audit review underway on closedown process
20
3 Strategic Objective
Board Reports
Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer
Principal Risks RAG
Key Controls
Risk Owner 3.3) Effective transition and delivery of Public Health functions to new commissioning landscapes may not be achieved
Amb er
Transition plans for transfer of Public health functions to the Local Authority agreed by cluster board, local authorities and SHA.
Assurances on Controls
Board and Cluster Executive Team (CET) updates on progress with the development of the plans
Key Positive Assurance
Gaps in Control (GIC) and/or
(**External / Independent)
Gaps in Assurance (GIA)
Corrective Action
Significant Letter from SHA agreeing each PCT’s individual plan APL 12
Reasonable Director of Corporate Development and Transition, & Directors of Public Health (3) attend PH transition groups with each Local Authority.
Responsib ility Target Date
Board report re implementation of plan
GIA
Setting up a series of planning meetings to implement the transition
Some elements of national guidance still awaited.
DPHs st
31 October 2012
Plans to be updated on receipt of complete information.
Limited
Risk Owner: Gill Galdins
Risk Manager (s)
Shadow working arrangements with local authority in place, with Memorandum of Understanding on staffing in place
Andrew Furber
21
3 Strategic Objective
Board Reports
Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer
Principal Risks RAG Risk Owner
Key Controls
Assurances on Controls
Key Positive Assurance
Gaps in Control (GIC) and/or
(**External / Independent)
Gaps in Assurance (GIA)
Corrective Action
Responsib ility Target Date
Judith Hooper Graham Wardman
22
3 Strategic Objective
Board Reports
Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer Principal Risks
Key Positive Assurance Key Controls
Risk Owner
RAG
3.4 )Lack of robust clinical workforce, training, planning and performance data across the commissioning economy may lead to insufficient clinical skills and failure to deliver expected outcomes.
Amb er
Assurances on Controls (**External / Independent)
Health Economy Risk Assessment Process annually
LDA Schedule 3 documents.
Programme of workforce assurance meetings in place with key Providers
Workforce integration of Board performance reports bi-monthly.
Training Needs analysis undertaken.
Board Performance reports includes Staff in Post against trajectory plus turnover plus sickness absence.
Significant
Gaps in Control (GIC) and/or Gaps in Assurance (GIA)
Corrective Action
Responsib ility Target Date
(GIC)
SHA reviews of Schedule 3
Implementation of OLM to ensure Cluster Mandatory Training take-up.
People transition policies adopted and process ongoing.
(GIA)
Turnover monitored in cluster via workforce scorecards.
CQC registration.
Training plan to be approved
Reasonable Risk Owner:
Business Continuity Plans in place to prioritise work
June GoodsonMoore Assignment to CCG and CSO roles (letter dated January
National staff survey results and actions plans report to Board and CCE
Training Plan including
Limited
23
3 Strategic Objective
Board Reports
Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer Principal Risks
Key Positive Assurance Key Controls
Risk Owner Risk Manager (s) Laura Smith
Assurances on Controls
RAG
(**External / Independent) 2012).
Provision of career development and resilience support to staff.
Gaps in Control (GIC) and/or Gaps in Assurance (GIA)
Corrective Action
Responsib ility Target Date
mandatory training approved at Cluster Leadership Team (Aug 2011)
Shared working across Cluster within functions.
PDR process and time management support. Escalate workforce planning issues with providers as appropriate.
24
3 Strategic Objective
Board Reports
Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer Principal Risks Key Controls Risk Owner
RAG
3.5) The Cluster workforce in transition is not supported and managed effectively, allowing business critical staff to leave and failing to delivery key priorities and not developing the new commissioning landscapes.
Amb er
Sickness absence, staff in post and turnover is monitored monthly in each PCT. Positive employee relations and staff partnerships arrangements in place. Introduction of new West Yorkshire Workforce Transition Group across CKW and ABL as sub group of existing partnership arrangements Staff health and resilience initiatives in place.
Risk Owner: June GoodsonMoore
Monitor internal staff sickness levels and manage, in keeping with policy.
Risk Manager (s)
Business critical roles
Assurances on Controls
Cluster workforce scorecard reports.
Key Positive Assurance (**External / Independent)
Gaps in Control (GIC) and/or
Corrective Action
Gaps in Assurance (GIA)
Responsib ility Target Date
Significant Staff Survey 2011
(GIC)
Agreed CKW People Transition Policy Jan 2012 Regional Social Partnership Forum
Public health/CCG/CSO transition plans predicated on DH guidance
Board Performance Reports. Staff survey results and action plans to Board and CCE. Staff Forum in place – Calderdale. IIP Group, Kirklees.
Reasonable
Feedback timetable via Regional Social Partnership Forum
June GoodsonMoore
(GIA)
Employee relations and staff participation forums in place (Staff side meeting) Limited Workforce reports to individual SMTs as well as to Board
25
3 Strategic Objective
Board Reports
Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer Principal Risks Key Controls Risk Owner
RAG
Laura Smith
Assurances on Controls
Key Positive Assurance (**External / Independent)
Gaps in Control (GIC) and/or
Corrective Action
Gaps in Assurance (GIA)
Responsib ility Target Date
identified.
Susan Moloney
3 Strategic Objective
Board Reports
Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer Key Positive Assurance
Principal Risks Key Controls Risk Owner 3.6) Cluster
RAG Amb
Revised governance arrangements
Assurances on Controls
NCB
Gaps in Control (GIC) and/or Corrective Action
(**External / Independent) Significant
Gaps in Assurance (GIA)
Responsib ility Target Date
GIC
26
3 Strategic Objective
Board Reports
Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer Key Positive Assurance
Principal Risks Key Controls Risk Owner Governance arrangements are not fully embedded therefore decisions may be made without due authority.
Risk Owner: Gill Galdins
Matt Walsh Carol McKenna Chris Dowse Jo Webster
RAG er
approved by Cluster Board to reflect system changes from 1 October 2012.
Designate Chief Officers participate in Board meetings and present report on governance and risk issues in CCGs.
SOS/SFIs reviewed and updated to reflect changes in senior team and delegation to CCEs (June 2012)
Reviewed Terms of Reference for Board Committees to reflect system changes. Procurement Committee established to ensure procurement decisions made appropriately given reduced frequency of Board meetings.
Assurances on Controls
authorisation process reviewing CCG governance arrangements
Gaps in Control (GIC) and/or Corrective Action
(**External / Independent)
Gaps in Assurance (GIA)
Responsib ility Target Date
SHA – CCG Risk Ratings Internal Audit review of governance significant assurance Reasonable
Recommendatio ns from NHSCB on CCG authorisation Limited
CCGs currently populating structures for governance arrangements (in-house or via CSU SLAs)
Structures near to completion as at 20.12.12
Governance arrangements with West Yorkshire Local Area Team for NHS Commissioning Board to be developed once key staff in post.
GIA
27
3 Strategic Objective
Board Reports
Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer Key Positive Assurance
Principal Risks Key Controls Risk Owner
RAG
Assurances on Controls
(**External / Independent)
Gaps in Control (GIC) and/or Corrective Action Gaps in Assurance (GIA)
Responsib ility Target Date
Chair’s Action procedure ensures governance process for any urgent decisions is clear and documented.
CCG preparedness on governance tested by NHSCB through authorisation process
3 Strategic Objective
Board Reports
Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer
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Principal Risks Key Controls Risk Owner
RAG
3.7) Unauthorised access, loss or damage to data occurs due to inadequate information governance arrangements
Amb er
IG Toolkit submissions. Previously PCT based, Cluster based for 11/12
Local Audit and Governance groups have information governance in their Terms of Reference.
Assurances on Controls
Key Positive Assurance
Gaps in Control (GIC) and/or
(**External / Independent)
Gaps in Assurance (GIA)
Baseline and improvement plan considered by CET and by Governance Committee as reported February 2012
Significant
GIA
External: Risk Owner: Peter Flynn
Risk Managers:
Port control and encryption implemented
Transition and close down board established.
Terry Service, Risk register updated on key risks
Risk register reviewed by key organisations
Annual review by Internal Audit
Calderdale – Emergency Planning business continuity test included information governance
ABL appointed to support transition and closedown programme including records. Reasonable
Corrective Action
Responsib ility Target Date
Records management audit action plan across the cluster.
Risk Owner: Q3/4 12/13
Corporate records audit underway for NHSK
Review of corporate records completed for NHSWD and NHSC. Limited
Internal Audit report on Cluster 11/12 submission awaited.
On receipt of Internal Audit report, a paper to describe any further necessary corrective action will be submitted to the Cluster and CCG Audit Committees
Risk Owner: Expected Q3 12/13
GIC
Cluster IG toolkit score
Inclusion if IG in CCG Authorisation process
29
3 Strategic Objective
Board Reports
Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer Principal Risks Key Controls Risk Owner
RAG
Assurances on Controls
Key Positive Assurance
Gaps in Control (GIC) and/or
(**External / Independent)
Gaps in Assurance (GIA)
Corrective Action
4 Strategic Objective
Responsib ility Target Date
Board Reports
Deliver the New Commissioning System Infrastructure Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development – Updated by Ann Ballarini on 03/12/2012
Principal Risks Key Controls Risk Owner
4.1) Clinical
RAG
Amb
Each eCCG has PCT staff
Assurances on Controls
Board to Board
Key Positive Assurance
Gaps in Control (GIC) and/or
(**External / Independent)
Gaps in Assurance (GIA)
Corrective Action
Significant
2 practices currently not
Responsib ility Target Date
Support provided through
30
4 Strategic Objective
Board Reports
Deliver the New Commissioning System Infrastructure Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development – Updated by Ann Ballarini on 03/12/2012
Principal Risks Key Controls Risk Owner
Commissioning Groups fail to achieve authorisation due to ineffective support from PCTs.
Risk Owner: Ann Ballarini Risk Manager (s) Danny Alba
RAG
er
working with them to support their application for authorisation this includes an aligned shadow accountable officer OD lead and finance support.
Clear Programme Office structure in place which describes the areas of transition, timescales and leads with a designated coordinator for a portfolio that includes eCCG development and authorisation.
Assurances on Controls
Key Positive Assurance
Gaps in Control (GIC) and/or
(**External / Independent)
Gaps in Assurance (GIA)
Corrective Action
Reviews
Delivery against the key milestones for eCCG authorisation is monitored through the Commissioning Development Assurance Framework with the SHA
Confirmation that configuration of each CCG is appropriate by NHSCB.
COO to reach a conclusion to this and offered from the Cluster leads. Issue resolved.
June 2012
Delay in the alignment of staff to eCCGs Wave 1 Calderdal e and Wakefield CCGs complete d Nov 2012
Final Evidence report from NHSCB
CCG Authorisation process. Development and OD Plan in place
allocated to an eCCG. Discussion on going to finalise arrangements With existing eCCG.
Responsib ility Target Date
Reasonable
Potential weak areas in the assessment against the 6 areas for authorisation which may lead to conditions being attached to final authorisation
Development of a plan to address any conditions with authorisation is being agreed with each CCG within the
Wave 2
31
4 Strategic Objective
Board Reports
Deliver the New Commissioning System Infrastructure Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development – Updated by Ann Ballarini on 03/12/2012
Principal Risks Key Controls Risk Owner
RAG
Confirmation of which wave each CCG is going to put in an application
Assurances on Controls
Key Positive Assurance
Gaps in Control (GIC) and/or
(**External / Independent)
Gaps in Assurance (GIA)
Corrective Action
Monthly and quarterly monitoring return to SHA
appropriate timeframe
Limited Compliance with the 6 domains required for authorisation
Submission of application for the appropriate wave deadline.
4 Strategic Objective
Review of progress through the Programme Office and clear reporting to the Cluster Board as a regular exception report..
Responsib ility Target Date
G Huddersfi eld CCG to be complete d by end December 2012
Wave 4
NKirklees by end January 2013
Board Reports
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Deliver the New Commissioning System Infrastructure Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development – Updated by Ann Ballarini on 03/12/2012 Principal Risks Risk Owner 4.2) New commissionin g support offer does not deliver requirements of eCCGs
Risk Owner: Ann Ballarini
Risk Manager (s) Rachel Spilsbury
Risk Status
Key Controls
Assurances on Controls
RAG Amber
Delivery against the key milestones of the Commissioning Development Assurance Framework for SHA which covers requirements of delivering the West Yorkshire CSU
Support through National and Regional team, membership of Regional DCD group and input to national workshops
Recruitment of ‘Managing Director’ for the West Yorkshire CSU in August 2012. Monthly joint committee meetings (sub-committee of both cluster boards). Structure now published and pooling and matching to posts is in progress.
Key Positive Assurance (**External / Independent) Significant
Monthly and quarterly reports to SHA
Board reports on progress and providing assurances against the key milestones for the development of the Prospectus, business plan and service level agreements
Feedback from BDU on checkpoints 1-3 received and satisfactory Reasonable
SHA monitoring
Gaps in Control (GIC) and/or
Corrective Action
Responsibility Target Date
Gaps in Assurance (GIA) WYCSU recruited MD August 2012
Feed back report for checkpoint 3 received from BDU October 2012
CSU structure agreed September 2012
Limited
Pooling and matching completed November 2012
SLA to be agreed with all 10 CCGs by end November 2012
Discussions progressing
33
4 Strategic Objective
Board Reports
Deliver the New Commissioning System Infrastructure Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development – Updated by Ann Ballarini on 03/12/2012 Principal Risks Risk Owner
Risk Status
Key Controls
RAG
Assurances on Controls
Key Positive Assurance (**External / Independent)
Gaps in Control (GIC) and/or
Corrective Action
Responsibility Target Date
Gaps in Assurance (GIA)
with CCGs to agree SLAs by end of November 2012.
34
4 Strategic Objective
Board Reports
Deliver the New Commissioning System Infrastructure Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development – Updated by Ann Ballarini on 03/12/2012
Principal Risks Risk Owner
Risk Statu s
Key Controls
Assurances on Controls
RAG 4.3) Development of an ineffective model for direct commissionin g function of NHS Commissionin g Board
Risk Owner: Ann Ballarini
Risk Manager (s) Louise Auger and Danny Alba
Ambe r
Delivery against the key milestones of the Commissioning Development Assurance Framework which covers requirements of preparing for the hand over to the NHSCB
Clear Programme Office structure in place which describes the areas of transition, timescales and designated coordinator for each portfolio. System in place to performance review against the key milestones and to identify areas of risk and mitigating actions.
Monthly and quarterly returns
Clear reporting to the Cluster Board as a regular exception report.
Agenda of monthly DCD meeting with SHA
Key Positive Assurance (**External / Independent) Significant
Gaps in Control (GIC) and/or Gaps in Assurance (GIA)
GIC Lack of national guidance on how NCB functions will be discharged.
Reasonable
Corrective Action
Director of Commissioning in WY LAT not yet recruited
National recruitment of Director
Responsib ility Target Date
Published November 2012
Cluster Director to oversee recruitment to structure until Director appointed.
Structures for the NHSCB Local Area Teams to be populated when published. Limited Pooling and matching to structure.
Complete d end November 2012
Clear leads for areas of work identified across the Cluster contributing to the 6 portfolios. Gaps in structure to be Sharing of information and intelligence
35
4 Strategic Objective
Board Reports
Deliver the New Commissioning System Infrastructure Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development – Updated by Ann Ballarini on 03/12/2012
Principal Risks Risk Owner
Risk Statu s
Key Controls
RAG across the Programme Office .
Assurances on Controls
Key Positive Assurance (**External / Independent)
Gaps in Control (GIC) and/or
Corrective Action
Gaps in Assurance (GIA)
advertised and recruited to .
Responsib ility Target Date
December 2012.
Director of Commissioning link to SHA meetings providing clarity on requirements and timescales.
Gateway for documents relating to this area provided by the SHA so that all relevant transition communications go directly to the DCD.
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5. Strategic Objective
Board Reports
Maintain the capacity to carry out Emergency Planning and Resilience during transition. Executive Director Lead; Judith Hooper Executive Director of Public Health Kirklees
Principal Risks Risk Owner
5.1a) Reduced capacity in PCT emergency preparedness teams leads to lack of preparedness for emergencies.
Risk Owner:
Risk Status
Key Positive Assurance Key Controls
RAG
Amber
Emergency planning teams are in place in each of the three PCTs, who work collaboratively across the cluster and across west Yorkshire to manage their workload effectively. In each PCT, a work plan is in place to ensure that essential preparedness work is completed.
Judith Hooper 5.1b) Reduced director-level capacity reduces ability of NHS to coordinate the healthcare response to an incident
Risk Owner:
Assurances on Controls
The director on call rotas have been merged across the cluster. This robust, fully staffed rota now includes around 20 staff is supported by an updated on call pack and staff call in lists. Up to date incident control rooms are maintained in all three PCT HQs
Local Emergency Planning meetings
Plans, Rotas and training records are maintained for all relevant systems.
Approved Major Incident Plans and a STAC plan are in place.
Debrief records from previous incidents, events and exercises.
Monthly communications tests and annual exercises, e.g Exercise Vespa (November 2011), Exercise Agora (July 2011)
(**External / Independent)
Significant
Gaps in Control (GIC) and/or
Corrective Action
Gaps in Assurance (GIA)
No current gaps in assurance.- risks on RR
N/A
Responsib ility Target Date
N/A
All PCTs score 12
Reasonable Successful coordination of planning for and response to industrial action in November 2011 Limited
Exercise Vespa Exercise Agora SHA assurance March 2012 return Exercise Chadwixk
37
5. Strategic Objective
Board Reports
Maintain the capacity to carry out Emergency Planning and Resilience during transition. Executive Director Lead; Judith Hooper Executive Director of Public Health Kirklees
Principal Risks Risk Owner
Risk Status
Key Positive Assurance Key Controls
Assurances on Controls
RAG
(**External / Independent)
Gaps in Control (GIC) and/or Gaps in Assurance (GIA)
Corrective Action
Responsib ility Target Date
Judith Hooper 5.1c) Reducing public health capacity reduces on call cover and ability to activate Scientific and Technical Advice Cell.
The cluster has a fully staffed Public Health on call rota. All rota members have received training in activating the STAC. The HPA nd operates a 2 on call rota
Some expectation that capacity could reduce towards April 2013 due to issues dedailedunder 5.2 below.
Risk Owner: Judith Hooper (Ben Fryer)
38
5. Strategic Objective
Board Reports
Maintain the capacity to carry out Emergency Planning and Resilience during transition. Executive Director Lead; Judith Hooper Executive Director of Public Health Kirklees
Principal Risks Risk Owner
Risk Statu s
Key Controls
Assurances on Controls
Key Positive Assurance
Gaps in Control (GIC) and/or
(**External / Independent)
Gaps in Assurance (GIA)
Significant
GIA - Lack of clarity on roles and responsibilities from DH
Corrective Action
Responsib ility Target Date
RAG 5.2). Gaps in future delivery model for Emergency Planning and Resilience in the NHS within Calderdale, Kirklees and Wakefield District
Risk Owner:
Amb er
Maintenance of existing local and West Yorkshire NHS planning for major incidents
Maintenance of Lead PCT role to represent the NHS at West Yorkshire Resilience Forum activities
Winter planning system and winter plan
Judith Hooper (Ben Fryer)
Active engagement with discussions on future health protection arrangements across the region
Bimonthly West Yorkshire Resilience Forum Health Subgroup meetings
New Local Health Resilience Partnership established
Updates provided for NHS partners at LRF meetings
Early agreement on providing emergency planning capacity within Local
Insufficient capacity in place within NHS CB Area Teams. Reasonable MOU for provision of additional emergency preparedness capacity is not yet in place.
Continued negotiation with Local Authorities to ensure that emergency preparedness capacity is retained within the system.
Judith Hooper Ben Fryer
Jan 13 MOU required prior to April 2013
Limited
LHRP Established
39
5. Strategic Objective
Board Reports
Maintain the capacity to carry out Emergency Planning and Resilience during transition. Executive Director Lead; Judith Hooper Executive Director of Public Health Kirklees
Principal Risks Risk Owner
Risk Statu s
Key Controls
Assurances on Controls
Key Positive Assurance
Gaps in Control (GIC) and/or
(**External / Independent)
Gaps in Assurance (GIA)
Corrective Action
Responsib ility Target Date
RAG West Yorkshire Health Protection memorandum of understanding
Authorities.
40
6. Strategic Objective
Board Reports
Maintain full engagement in the provider development agenda to ensure effective partnership with current and future Foundation Trusts Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development Trusts – Updated by Ann Ballarini – 03/12/2012
Principal Risks Risk Owner
Risk Statu s
Key Positive Assurance Key Controls
Assurances on Controls
RAG 6.1) Local trusts fail to achieve foundation trust status due to lack of sufficient support from commissioners
RED
Mid Yorkshire Hospitals NHS Trust (MYHT) MYHEFT programme set up with a plan and 4 key work streams. Structures are in place to support the transactional aspects of the FT application process. Governance is provided through the MYHEFT Board which meets every two months and the smaller executive group which meets every fortnight, led by a Programme Director. Regular high level meetings between MYHT, CKW Cluster and SHA to agree financial recovery plan. Regular meetings between CCG GPs and MYHT clinicians
Minutes of meetings
(**External / Independent)
Report on CCGs’ commissioning intentions provided to MYHT and Cluster senior team.
Whole System Transformation event held Nov 11. Report on
Corrective Action Gaps in Assurance (GIA)
Significant Financial balance
Board papers QIPP outcome report sent to HEFT Executive group, Cluster CE, Cluster DoF, Wakefield District and Kirklees COOs, MYHT DoF and Dir Strategy Dec 2011 for action.
Gaps in Control (GIC) and/or
System wide review to create opportunities to improve financial resilience
Responsibilit y Target Date
HEFT/PMO Ongoing
Outline Business case and Full business case Regular updates on financial plans on aspirant FT
Reasonable
Limited
Risk register in circulation MYHT HEFT high level risk register
October 2012 Transformation Board set up with Jo Webster as RO
October 2012
41
6. Strategic Objective
Board Reports
Maintain full engagement in the provider development agenda to ensure effective partnership with current and future Foundation Trusts Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development Trusts – Updated by Ann Ballarini – 03/12/2012
Principal Risks Risk Owner
Risk Statu s
Key Positive Assurance Key Controls
Assurances on Controls
RAG
Risk Owner:
to work through Clinical Service Strategy options.
priorities widely circulated for action
Ann Ballarini Board updates through PO papers
(**External / Independent)
Gaps in Control (GIC) and/or Corrective Action Gaps in Assurance (GIA)
Programmes of work managed by a programme office set up.
Responsibilit y Target Date
October 2012 OBC Jan 2013
Programme Director recruited Risk Manager (s)Jo Webster
Julia Docherty
OBC Jan 2013
Chris Dowse
Danny Alba
42
6. Strategic Objective
Board Reports
Maintain full engagement in the provider development agenda to ensure effective partnership with current and future Foundation Trusts Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development Trusts
Principal Risks Risk Owner
6.2) Fail to deliver effective implementation of Any Qualified Provider (AQP) as set out in the guidance on 19 July 2011.
Risk Status
Key Positive Assurance Key Controls
RAG
Green
1. Delivery against the key milestones of the Commissioning Development Assurance Framework, i.e. 3b.4.1 Clusters to have signed off priority AQP services with SHAs and 3b.4.2 Clusters to have started delivery of at least 3 AQP community and mental health services, working in partnership with CCGs;
2. Project delivery trajectories for Phase 1 AQP implementation and Phase 2 AQP implementation; Risk Owner: Ann Ballarini
Risk Manager (s) Rachel Carter and Danny Alba
Assurances on Controls
3. Stakeholder (includes key providers) engagement and consultation process and activities;
1. Commissioning Development Portfolio is coordinated by the NHSCKW Programme Management Office (PMO) with the DCD as senior responsible owner;
(**External / Independent)
Significant AQP contracts now let with implementation of service delivery underway. Reasonable
2. Regular report to Cluster Board and CCEs; Limited 3. Heads of contracting from each PCT comprising the Cluster as designated leads.
Gaps in Control or Assurance
Corrective Action
(GIA) or (GIC)
GIA) None identified
(GIC) DH policy changes / directives that may influence phase 2 list of services suitable for AQP procurement not yet available.
GIC) Further central guidance expected imminently and being scanned for. Engagement in Y&H planning (11th January) and North of England event (25th January). Project delivery trajectory for Phases 1 and 2 AQP implementation are amenable to adjustment in light of anticipated DH policy guidance, including expected standardised AQP service specifications.
Responsib ility Target Date
Local eCCGs supported by NHSCKW heads of contractin g. Rachel Carter, Matt England & Martin Pursey
Patient choice of AQP for relevant services being implemented as at December 2012 (wheelchair services is the only AQP with agreed national delay).
4. DH guidance / directive on a future selection of services suitable for AQP,
43
6. Strategic Objective
Board Reports
Maintain full engagement in the provider development agenda to ensure effective partnership with current and future Foundation Trusts Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development Trusts
Principal Risks Risk Owner
Risk Status
Key Positive Assurance Key Controls
RAG
Assurances on Controls
(**External / Independent)
Gaps in Control or Assurance (GIA) or (GIC)
Corrective Action
Responsib ility Target Date
and dissemination of standardised AQP service specifications for use in AQP procurements. 5. Communication and engagement strategy with key stakeholders (includes key providers) to determine services suitable for AQP; 6. AQP within eCCGs' commissioning intentions / operating plans.
44
6. Strategic Objective
Board Reports
Maintain full engagement in the provider development agenda to ensure effective partnership with current and future Foundation Trusts Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development Trusts
Principal Risks Risk Owner
Risk Statu s
Key Controls
Assurances on Controls
Key Positive Assurance
Gaps in Control or Assurance
(**External / Independent)
(GIA) or (GIC)
Corrective Action
Responsib ility Target Date
RAG 6.3) Insufficient oversight of the ‘NHS organisation failure regime’ within the cluster geographical area of responsibility.
Risk Owner: Peter Flynn
Risk Manager (s): None Identified
Amb er
Accountability framework implemented for all KPIs at Cluster & PCT catchment level.
Contract Management Groups, Quality Groups and Executive Contract Boards for each main contract with key providers review performance, activity, finance and quality monthly.
Reports on12/13 Operating Framework KPIs with underperformance &exception reporting for Provider and PCT Catchment presented to CCGs F&P Committees DH/SHA monitoring of data and feedback to Cluster on areas of under performance
Performance reporting to Cluster Board at Cluster level and
Significant GIC
Reasonable External monthly scrutiny by the North of England SHA of high level performance measures in the CKW health economy Limited
GIA
Performance roles in CCGs are relatively junior.
Support through CSS
CCG Accounta ble
45
6. Strategic Objective
Board Reports
Maintain full engagement in the provider development agenda to ensure effective partnership with current and future Foundation Trusts Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development Trusts
Principal Risks Risk Owner
Risk Statu s
Key Controls
Assurances on Controls
Key Positive Assurance
Gaps in Control or Assurance
(**External / Independent)
(GIA) or (GIC)
Corrective Action
Responsib ility Target Date
RAG Part of OD Plan and CSS Development
from CCGs
7. Strategic Objective
Officers By end of Q4 12/13
Board Reports
Deliver high quality Communications and Engagement Executive Lead; Mike Potts Chief Executive Officer
46
Principal Risks Risk Owner
Risk Statu s
Key Controls
Assurances on Controls
Key Positive Assurance
Gaps in Control or Assurance
(**External / Independent)
(GIA) or (GIC)
Workforce report to Board
Significant
Corrective Action
Responsib ility Target Date
RAG 7.1) Staff are not fully engaged in the reforms in line with the NHS Constitution
Amb er
Clusterwide shared communications and engagement team in place and fully functioning.
Monthly internal staff briefing – includes operational, transitional and HR input from CCGs, Cluster, and public health.
(GIA) Staff survey 2011- cluster response 74%.
Reasonable
No staff forum arrangement in Wakefield
Risk Owner: Gill Galdins
Risk Manager (s) Eleanor Nossiter
Consistent weekly bulletin across Cluster.
(GIC) Will be covered by joint Cluster forum being established
Limited
Creation of Cluster Intranet
Comms team members sit as part of the public health transition groups.
Staff awards and ‘moving on’ celebrations arranged
47
7. Strategic Objective
Board Reports
Deliver high quality Communications and Engagement Executive Lead; Mike Potts Chief Executive Officer
Principal Risks Risk Owner
Risk Statu s
Key Controls
Assurances on Controls
Key Positive Assurance
Gaps in Control or Assurance
(**External / Independent)
(GIA) or (GIC)
Corrective Action
Responsib ility Target Date
RAG across the Cluster.
Internal comms coordinated with ABL to ensure consistency of messages – in preparation for move to WY CSU.
48
Board Reports 7. Strategic Objective Deliver high quality Communications and Engagement Executive Lead; Mike Potts Chief Executive Officer – Updated by Eleanor Nossiter on 07/12/2012
Principal Risks Risk Owner
Risk Statu s
Key Controls
Assurances on Controls
Key Positive Assurance
Gaps in Control or Assurance
(**External / Independent)
(GIA) or (GIC)
Corrective Action
Responsib ility Target Date
RAG
7.2) Fail to ensure constituent PCTs continue to meet their statutory responsibilities for communication and engagement
Risk Owner: Gill Galdins
Risk Manager (s)
Amb er
Comms and engagement steering groups for MY and C&H transformation programmes
Regular engagement with local MPs
Daily monitoring of media coverage.
Communication and Engagement Strategies developed for CCGs
Communications and Engagement development sessions for CCGs
Weekly monitoring conference calls with Mid Yorkshire & SHA
Communications and Engagement is standing item on agenda of the two transformation boards
Significant Pre-consultation communications and engagement plan for MY programme agreed with Joint OSC Reasonable
Limited
(GIA)
Capacity issues in comms and engagement – insufficient staffing resource to cover all requirements of CCGs, Cluster and two transformation programmes.
Escalated to SROs to progress discussions with CSU.
Eleanor Nossiter
Jan 2013 Seeking temporary external support to March 2013.
Lack of clarity regarding funding and hosting for comms and engagement support for transformation programmes post-April 13.
(GIC)
49
Board Reports 7. Strategic Objective Deliver high quality Communications and Engagement Executive Lead; Mike Potts Chief Executive Officer – Updated by Eleanor Nossiter on 07/12/2012
Principal Risks Risk Owner
Risk Statu s
Key Controls
Assurances on Controls
Key Positive Assurance
Gaps in Control or Assurance
(**External / Independent)
(GIA) or (GIC)
Corrective Action
Responsib ility Target Date
RAG Eleanor Nossiter Three out of four CCGs have completed their authorisation visits, with no outstanding ‘reds’ for domain 2 (the domain to which comms and engagement contributes most).
Governance Committee Terms of Reference
PPI Engagement annual reports sign off by Board and CCE.
50
Principal Risks:are what could prevent key objectives from being achieved. Key risks should be true risks (rather than consequences), and so cannot just be the converse of the objective. Risk Status:(green, amber or red).This shows the ‘traffic lighting’applied to each risk, andseeks to help the Board ‘weight’ the amount of attention that it directs in reviewing entries on the Assurance Framework. The risk status is updated quarterly using the risk matrix
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received.
Amber – the risk is increasing either through gaps in control or as a result of actions not being fully embedded and / or insufficient assurance on controls.
Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
Key Controls:are factors, systems or processes that are in place to mitigate the principal risk(s) and assist in securing delivery of the relevant key objective. Key controls should be robust and specific, and properly match the associated key objective(s). For example; a sub committee or committee of the Board which is tasked with monitoring the specific risk.
Assurance on Controls:are sources of evidence that the key controls are effective. Assurances should be matched with specific key control(s) wherever possible.
Key Positive Assurance: assessment seeks to measure the level of assurance with which it can be determined that the key controls are mitigating the principal risks identified. The assessment also specifies how/where the organisation has evidence showing that principal risks are being managed reasonably. Descriptions should provide sufficient details to identify specific documentary evidence, e.g. dates of meetings, publications, reviews etc. External or Independent assurances are generally given more weight than internal sources.
Gaps in Control: indicates where the organisation has failed to put key controls in place, or has failed to make key controls effective.
Gaps in Assurance: indicates where the organisation is failing to gain evidence that key controls are effective.
51
Corrective Action: shows what will or is being done to address the gap(s) in control or assurance.
Responsibility / Target Date:shows the Director (or senior manager) responsible for appropriate and timely implementation of corrective action(s) and the expected date by which actions should be completed.
Progress reports provide a quarterly update on achievement of action plans and identify where gaps in control or assurance have been addressed. They should also indicate where the risk grading has changed for any risks associated with that objective.
Generally, Assurance Frameworks should map key objectives to principal risks, key controls and assurances explicitly. Assurance frameworks should be embedded and dynamic, providing regular Board information and not viewed as year-end exercises.
Assurance
Examples of what constitutes differing levels of assurance:
Key Positive assurance (** External/Independent) EXAMPLES OF TYPES OF ASSURANCE
52
**SHA Audit of data quality indicating no significant concerns, reported to Trust Board January 2011, Clinical Commissioning Executive Committee February 2011. (significant assurance) **CQC indicators met for relevant targets as reported in periodic review, October 2011 (significant assurance) Performance Report received by the Trust Board,most recent September 2011, showing performance within tolerance for overall achievement of target for Q1 (reasonable assurance) Contract monitoring report to Clinical Commissioning Executive Committee in September 2011 showing performance within tolerance for overall achievement of target for Q1 (reasonable assurance) Performance report to Trust Board, most recent September 2011, indicating current position against key targets (limited assurance)
Significant Assurance 2011/2012 prospectus published March 2011, included for information in Board papers May 2011 Uptake report on attendance at Health & Safety courses at Health & Safety working group November 2011 shows 60% of staff have attended relevant courses, compared with 40% last year Reasonable Assurance Update report to audit and governance committee September 2011 demonstrating 80% of required courses now established Limited Assurance Performance report to Trust Board, most recent September 2011, indicating current position against key targets
Key Positive assurance
EXAMPLE OF LAYOUT
Beginners Guide to Board Assurance\BAF Sources of Assurance.doc Note. The risk status does not necessarily mirror the positive assurance assessment. For example, it is possible that work may be well on track (or ahead of plan) to develop controls or address a risk, and hence management may determine that the risk status be assessed as ‘green’. However, because that work is not complete, the positive assurance assessment may be ‘limited assurance’, with actions identified to complete the relevant work
53