NHS Calderdale, Kirklees and Wakefield District Cluster
Minutes of the Cluster Governance Committee held on 23 November 2012 at 9.00am in Interview Room 9, Broad Lea House, Huddersfield
Present: Angela Monaghan Roy Coldwell Sandra Cheseldine In attendance: Gill Galdins Deborah Turner Andrea McCourt Alison Fearnley Craig Danks Terry Service Ian Wilkinson
Cluster Chair Non Executive Director Non Executive Director
Director of Corporate Development and Transition Head of Quality and Patient Safety (NHS North Kirklees CCG) Head of Corporate Governance (NHS Wakefield District) Corporate Governance Administrator (NHS Kirklees) Transition Programme Manager – Calderdale, Kirklees and Wakefield Assistant Director of Corporate and Risk (NHS Kirklees) (Agenda Item GC/12/78 & 79) Safety and Security Manager (NHS Calderdale) (Agenda Item GC/12/78 & 79)
It was noted that Angela Monaghan had agreed to Chair the meeting in the absence of Roger Grasby, regular Chair of the Cluster Governance Committee. GC/12/68
Apologies for Absence Apologies for absence were received from Roger Grasby, Non Executive Director, Sue Cannon, Executive Director of Quality and Governance (Executive Nurse) and Judith Salter, Assistant Director of Transition (NHS Calderdale).
GC/12/69
Declarations of Interest No Governance Committee members declared interests in any of the agenda items.
GC/12/70
Minutes of the last meeting held 10 October 2012 The minutes of the last meeting held on the 10 October 2012 were AGREED as a true and accurate record and the Action log sheet was reviewed and updated as necessary.
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GC/12/71
Internal Audit Report – Quality Governance Framework It was noted that Internal Audit was commissioned to test out the effectiveness of the Quality Governance in emerging Clinical Commissioning Groups. The outcome of this review was reported to the Governance Committee, noting that this was a draft report. It was noted that the overall audit opinion was that there was ‘Significant Assurance’ meaning; there is generally a sound system of internal control designed to address the risk that the system objectives are not fully achieved. However it was recognised that there are some weaknesses in design and/or non-compliance with controls that could put some of the system objectives at risk. Deborah Turner summarised the draft key findings from the Internal Audit review in more detail. These included: •
Structures and Strategy It was noted that the review provided ‘Significant Assurance’. It was noted that there were some issues around attendance and quoracy with the Wakefield District and North Kirklees quality sub-groups which had now been resolved. Deborah advised that a Quality Strategy was to be piloted which would set out the priorities for delivering quality improvement.
• Provider Contracting and Monitoring arrangements It was noted that review provided ‘Significant Assurance’. It was highlighted that monthly Quality Board meetings were now being held with Locala. It was recognised that there is requirement within the contract with Locala to report Serious Incidents (SI), however none had previously been reported since awareness had been raised one SI had now been reported. • Information, reporting and learning It was noted that the review provided ‘Significant Assurance’. • Risk Management It was noted that the review provided ‘Full Assurance’ which was a very positive finding. • Quality Handover It was noted that the review provided ‘Significant Assurance’. It was confirmed that Version 2 of the Quality Handover document would be presented to the Governance Committee on 18 December 2012. The final draft would then be presented to the Cluster Board on 22 January 2013. Page 2 of 6
A discussion ensued regarding the handover of the quality documents. It was noted that documents would be handed over board to board rather than via key individuals. It was subsequently AGREED that documents should be handed over to the Accountable Officer/Senior Responsible Officer. Finally, it was noted that the report would be presented to each of the CCGs during December for their detailed comments. The Cluster Governance Committee RECOMMENDED that CCGs should look to raise standards where possible and where examples of good practice have been noted these should be rolled out to all CCGs. GC/12/72
Quality Handover Deborah Turner provided a verbal update regarding progress in developing the Quality Handover Document. Deborah provided assurance that the document was continuing to be populated and was confident that good progress was being made. It was highlighted that the due diligence processes would be included. It was emphasised that the documents need to be accessible and usable. It was therefore recommended that a ranking column is included to highlight areas of importance. Deborah described the information that would be included around Primary Care Performance following comments received from Roy Coldwell at the last meeting. Assurance was provided that the points raised in Roy’s email had been addressed. The committee highlighted the need to ensure that issues are not lost across the cluster following disaggregation. It was acknowledged that Version 2 of the Quality Handover document would be presented to the committee at the next meeting.
GC/12/73
Transition and Closedown Report Craig Danks joined the meeting to present the Transition and Closedown report. It was recognised that the highlight report summarised the key risks to the transition programme. It was acknowledged that transition and closedown risks are captured on the corporate risk register and are monitored by the Programme Office and through the Transition Steering Group, using the Programme Assurance Framework (PAF).
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The committee reviewed the progress to date on each of the workstream areas. The committee requested that future reports include an individual RAG rating and thresholds for each of the workstream areas. Future reports should also highlight the mitigating actions. It was also highlighted that the High Level Risk Log should be considered in conjunction with this report. The committee acknowledged that a Transition Newsletter was being developed which would also be circulated to Receiver organisations. Gill AGREED to share information on any transition events taking place that may be of interest to committee members. It was noted that Vanessa Stirum, Non Executive Associate, had been asked to attend future Transition Steering Group meetings and should also be invited to any other transition events taking place. Gill provided clarity regarding the workforce issues relating to the transfer of public health staff. It was recognised that the Remuneration and Terms of Service Committee was sighted on these issues. The committee sought assurance on the review process being undertaken in relation to primary care and contracts. Craig provided assurance there was clear guidance on this process and confirmed a contract stocktake was being undertaken. A discussion took place regarding the extension of existing contracts. It was emphasised that continuity of service should be maintained while complying with existing Standing Orders and Standing Financial Instructions. It was suggested there should be a standing agenda item in relation to this on each of the Audit and Governance sub groups. A discussion ensued regarding the due diligence process and how Receivers were scrutinising the work undertaken. Craig confirmed that information had been shared at the Receiver events held on 13th and 14th November and that a further event was being held on 11 December. Members of the committee were encouraged to attend this event. Communication between Sender and Receiver on progress with due diligence and other key processes will be discussed openly, with a view to agreeing an appropriate way to keep the lines of communication open outside of formal arrangements already in place. It was noted that Internal Audit had been commissioned to undertake a review of the DH guidance against the cluster transition project plan in order to provide assurance to the Governance Committee that the work being undertaken was in line with guidance. It was AGREED that the findings from this review would be reported to a future meeting when completed. It was also suggested that guidance for Receivers is also established.
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Craig AGREED to re-access the level of risk on Emergency Planning following a query raised by a committee member. It was noted that the Section 75 agreement, approved in principle at the last meeting regarding the transfer of Wakefield public health services to Wakefield Council was not likely to go ahead. Therefore services would transfer on 1 April 2013 the same as Kirklees and Calderdale. It was AGREED that this would be reported to the Board in January via the regular Governance Report. The committee acknowledged pressures on capacity now that staff alignment was taking place. It was emphasised that continuity of service was essential during the transition. The Governance Committee RECEIVED and NOTED the Transition and Closedown Report and acknowledged the action taken and the identified risks. GC/12/74
Risk Report, High Level Risk Log, Cluster Critical risks and Board Assurance Framework Terry Service and Ian Wilkinson joined the meeting to present the combined report. The BAF was reviewed page by page by the committee members. It was noted that a lot of the narrative was out of date. The Committee acknowledged that there were resource implications and were sympathetic to this. The committee requested that gaps in controls are updated and the adjacent columns are appropriately populated. It was AGREED that Terry would update the BAF with the comments from the Governance Committee so that this could be presented to the Audit Committee on 27 November 2012. Following this, Terry would send the individual risks to the risk owners to be updated within a two week timescale. Once updated this would be re-circulated to the Audit Committee members for final comment in mid December before being presented to the Cluster Leadership Team on 7 January 2013. The final version would then be presented to the Cluster Board on 22 January 2013 for formal sign off. The committee reviewed the High Level Risk Log (HLRL). It was recognised that this captures the risks scoring 15 and above. It was noted that there were a total of 29 risks on the CKW HLRL. These included: • • •
5 new risks 6 increased scores 18 risks had the same score as the last review
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The committee noted there was one critical risk at NHS Calderdale relating to the number of MRSA bacteraemia infections reported. The committee sought assurance on the mitigating actions. Following discussion, it was AGREED where a critical risk was reported the programme lead would be asked to present supporting evidence to the Governance Committee on the actions in place. Gill Manojlovic would therefore be invited to the next meeting. A discussion then took place regarding risk number 3201 in relation to Emergency Planning. The committee challenged why this risk only related to NHS Kirklees. It was AGREED this would be reviewed across the cluster. GC/12/75
Any Other Business •
CCE and devolved budgets Gill Galdins raised an issue with regard to the allocations and governance arrangements for devolving budgets to the CCEs following concern raised at the Board Business meeting on 6 November. It was AGREED Gill would raise this with the Cluster Leadership Team with a view to a proposal being taken to the Cluster Board in January 2013.
It was noted that discussion would take place in Part two of the meeting to be held in private with regard to the Performers Advisory Group. This discussion would be recorded separately.
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